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

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)
Infusion Pump
Model No.
  Infusion Pump
Serial No.
  Infusion Pump
Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date    
   

Previous Device Data (Complete if the following information for devices being replaced)
Infusion Pump
Model No.
  Infusion Pump
Serial No.
  Infusion Pump
Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date