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Step 1. Patient Information

Step 2. Implant Physician Information

Step 3. Following/Attending Physician Information

Step 4. Device(s) Information

Step 5. Review and Submit Registration

  -Review and confirm this registration.
  -When registration confirmation is returned, print a copy for your records

 

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Review and Confirmation
Review the information for this registration.
Items marked in yellow are incomplete.

Patient: LastName, FirstName  
Last Name   First Name Initial
 
Patient Chart Number   Sex Date of Birth
  M F
Social Security Number    
- -      

    Patient Expired

Address Line 1   Patient Telephone Number
Address Line 2
  ( )
City   State/Province   Postal Code
   
Country      
     
 

Implant Physician  
Last Name   First Name   MI
   
M.D.    D.O.      
First Specialty   Second Specialty
 

Telephone Number   Fax Number
( )   ( )
Address Line 1  
   
Address Line 2  
   
Address Line 3  
   
City   State/Province   Postal Code
   
 
Following/Attending Physician  
Last Name   First Name   MI
   
M.D.    D.O.      
First Specialty   Second Specialty
 

Telephone Number   Fax Number
( )   ( )
Address Line 1  
   
Address Line 2  
   
Address Line 3  
   
City   State/Province   Postal Code
   
 


ICD {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Implant Location
Abdominal
Pectoral
   

Diagnostic Reason
VF Sudden Cardiac Death
 
Atrial Fib/Flutter
 
Post MI (VT, VF)
 
Heart Failure
(Check NYHA Class)
VT Ventricular tachycardia
Supravent, Tachycardia
 
Other
 
I III
II IV

Previous Device Data
Model Number   Serial/Lot Number
 
Device Manufacturer
 
  Prior Implant Date
   
/
/
 
 
IPG {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Diagnostic Reason for Pacing
Atrial Bradycardia
Sinus Bradycardia
Sick Sinus Syndrome
AV Block
2° (Intermittent)
3° (Complete)
AV Node Ablation

 
Special
Tachy/Brady
Atrial Tachy
WS, CSS
HOCM
CHF
Long QT
Other
     
    Pacemaker Dependent

Concommitent Cardiac Conditions
Atrial Tachycardia
Non-Sinus
A-Fib/Flutter
Other
 
Other
PSVT, SVT
Nodal, Junctional Tachy
Ventricular Tachy
Previous MI
Cardiomyopathy
Valve Disease
Transplant
Other

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

Lead {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Location
Right Atrium   Superior Vena Cava
Right Ventricle   Coronary Sinus
Left Atrium    
Left Ventricle    

Pacing/Sensing Thresholds Lead measurements as measured by PSA or equivalent
Pulse Width   Voltage   Current
ms   V   ma
    Impedance   Sensing
    ohms   P/R Wave mV

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

The information above marked in yellow is not required for registration.

To complete this registration, press the confirm button below.

Medtronic.com will then display a printable version of the registration received. Please print this for your records.

 
 

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