IPG {Serial/Lot Number}  
Implantable Pulse Generator
Model Number
  Date of Implant
{filled in by server}    
IPG Manufacturer

Extensions
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     

Diagnostic Indication for Use
Sacral Nerve Stimulation for Urinary Dysfunction
Sacral Nerve Stimulation for Bowel Dysfunction
Dynamic Graciloplasty
Gastric Stimulation
Other
   

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