Lead {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
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Manufacturer        
  {Product Family -Medtronic Only}
Location
RA RV SVC LA LV CS

Lead measurements as measured by PSA or equivalent
Pacing/Sensing
Pulse Width   Voltage   Current
ms   V   ma
    Impedance   Sensing
    ohms   P/R Wave mV

Defibrillation Lead Measurements
High Voltage Pathway   DFT/LED   Impedance
  J   ohms

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