IRF {Serial/Lot Number}  
Receiver Model Number   Serial/Lot Number Date of Implant
{filled in by server}   {filled in by server}
Receiver Manufacturer
Extension Model Number   Serial/Lot Number  
   
Transmitter Model Number   Serial/Lot Number  
   

Diagnostic Reason
Arachnoiditis
 
Peripheral Causalgia
 
Peripheral Neuropathy
 
Post-Herpetic Neuralgia
Failed Back Surgery Syndrome
 
Phantom Limb/Stump Pain
 
Ischemic Peripheral Pain
 
Other Chronic, intractable, pain of trunk or limbs

Previous Device Data (Complete if the following information for devices being replaced)
IRF Model No.   IRF Serial No.   IRF Manufacturer
   
Prior Implant Date  
 
    This device replaces more than one previously implanted device