Extension {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
Manufacturer        
       

Previous Device 1 Data (Complete if the following information for devices being replaced)
Model Number   Serial/Lot Number     Replaced Date
       
Device Manufacturer  
   
Previous Device Status   Prior Implant Date
 

Previous Device 1 Data (Complete if the following information for devices being replaced)
Model Number   Serial/Lot Number     Replaced Date
       
Device Manufacturer  
   
Previous Device Status   Prior Implant Date