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

Parameter Settings
Pacing Mode
Lower Rate ppm
Upper Rate Activity ppm
AV Interval Paced ms
 
Mode Switch
On Off
Upper Rate Tracking ppm
AV Interval Sensed ms

Atr Settings   Ventricular Settings
Atr Amplitude . V
Atr Pulse Width . ms
Atr Sensitivity . mV
Electrode Configuration
Atr Pacing
Unipolar Bipolar
Atr Sensing
Unipolar Bipolar
 
Vtr Amplitude . V
Vtr Pulse Width . ms
Vtr Sensitivity . mV
Electrode Configuration
Vtr Pacing
Unipolar Bipolar
Vtr Sensing
Unipolar Bipolar