Lead {Serial/Lot Number}
Defibrillation Lead Model Number   Date of Implant Same date as
{filled in by server}   Primary Device

Location
Right Atrium   Left Atrium
Right Ventricle   Left Ventricle
 

Defibrillation Lead Measurements
High Voltage Pathway   DFT/LED   Impedance
  J   ohms

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

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