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Medtronic

Pain

Step 1. Patient Information

Step 2. Implant Physician Information

Step 3. Following/Attending Physician Information

Step 4. Device(s) Information

  -Choose which items are being implanted
  -Complete specific information for Infusion Pump {Serial Number}
  -Complete specific information for Catheter {Serial Number}
  -Complete specific information for Catheter {Serial Number}

Step 5. Review and Submit Registration

 

 

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Medtronic
Patient: LastName, FirstName  
Specific Implant Device Information
Infusion Pump {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Drug Indicated
Morphine   Baclofen   Floxuridene
Other    

Diagnostic Indication for Use
Malignant Pain
Type of Cancer

Primary site of pain:
Spine/Back
Abdominal/Visceral
Thoracic
Extremity
Head/Neck
Pelvic
Other

  Non-Malignant Pain
Cause:
Failed Back Syndrome
RSD/Causalgia (CRPS)
Osteoporosis
Joint Pain/Arthritis
Post-Herpetic Neuralgia
Peripheral Neuropathy
Other
Intractible Spasticity   Cancer Chemotherapy
Cause:
Cerebral Palsy
Brain Injury
Multiple Sclerosis
Spinal Cord Injury/Disease
Other
 
Type of Cancer:
Liver, Metastatic or Primary
Renal Cell
Prostate
Other

Calibration Constant/Flow Rate
mg/ml  

Previous Device Data
Model Number   Serial/Lot Number
 
Device Manufacturer
 
  Prior Implant Date
   
/
/
 

 
 

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