Tachy Lead Model Number Serial Number Date of Implant
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Location
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Lead measurements as measured by PSA or equivalent
Pacing/Sensing
Pulse Width Voltage Current
{filled in by server} ms   {filled in by server} V   {filled in by server} ma
Impedance Sensing
{filled in by server} ohms P-Wave {filled in by server} mV
Previous Device 1 Data
Lead Model No. Lead Serial No. Lead Manufacturer
{filled in by server}   {filled in by server}   {filled in by server}
Previous Device Status Prior Implant Date
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Device Replaced Date    
{filled in by server}    
Previous Device 2 Data
Lead Model No. Lead Serial No. Lead Manufacturer
{filled in by server}   {filled in by server}   {filled in by server}
Previous Device Status Prior Implant Date
{filled in by server}   {filled in by server}
Device Replaced Date    
{filled in by server}