ICD {Serial/Lot Number}  
ICD Model Number   Date of Implant  
{filled in by server}    
Implant Location   Adaptor(s)/Patch(s) Used
Abdominal
Pectoral
Other
 
Model # Serial #
Connector   Connector Serial/Lot Number
B D E H CX
 

Diagnostic Reason
VF Sudden Cardiac Death
 
Heart Failure
(Check NYHA Class)
 
Atrial Fib/Flutter
 
Post MI (VT, VF)
VT Ventricular tachycardia
 
I III
II IV
 
Supravent, Tachycardia
 
Other

Previous Device Data (Complete if the following information for devices being replaced)
ICD Model No.   ICD Serial No.   ICD Manufacturer
   
Prior Implant Date  
 

Previous Device Data (Complete if the following information for devices being replaced)
ICD Model No.   ICD Serial No.   ICD Manufacturer
   
Prior Implant Date