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

Implant Position   Implant Technique
Aortic
Mitral
Tricuspid
Pulmonary
Other
 
Complete Subcoronary
Full Root
Modified Subcoronary
Root Inclusion
Unknown
Other

If multiple valve replacement, submit seperate registration form for each device implanted.

   

Was patient death related to product?

    No Yes

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