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Pain

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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Medtronic
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
   
 


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 Indication for Use
Essential Tremor
Parkinsonian Tremor
Other
   

Implant Position
Left
 
Right
       

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
Arachnoiditis
 
Causalgia
 
Peripheral Neuropathy
 
Post-Herpetic Neuralgia
Failed Back Surgery Syndrome
 
Phantom Limb/Stump Pain
 
Peripheral Pain
 
Other Chronic, intractable, pain of trunk or limbs

Implant Position
Left
 
Right
       

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

IRF {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
Arachnoiditis
 
Causalgia
 
Peripheral Neuropathy
 
Post-Herpetic Neuralgia
Failed Back Surgery Syndrome
 
Phantom Limb/Stump Pain
 
Peripheral Pain
 
Other Chronic, intractable, pain of trunk or limbs

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 Indication for Use
Sacral Nerve Stimulation for Urinary Dysfunction
Gastric Stimulation
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   Implant Position
Thalamus
Other
 
Brain
Left Side Right Side

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}

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

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

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

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

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

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

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

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

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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