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Pain

Step 1. Patient Information

Step 2. Implant Physician Information

Step 3. Following/Attending Physician Information

Step 4. Device(s) Information

Step 5. Review and Submit Registration

  -Review and confirm this registration.
  -When registration confirmation is returned, print a copy for your records

 

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Review and Confirmation
Review the information for this registration.
Items marked in yellow are incomplete.

Patient: LastName, FirstName  
Last Name   First Name Initial
 
Patient Chart Number   Sex Date of Birth
  M F
Social Security Number    
- -      

    Patient Expired

Address Line 1   Patient Telephone Number
Address Line 2
  ( )
City   State/Province   Postal Code
   
Country      
     
 

Implant Physician  
Last Name   First Name   MI
   
M.D.    D.O.      
First Specialty   Second Specialty
 

Telephone Number   Fax Number
( )   ( )
Address Line 1  
   
Address Line 2  
   
Address Line 3  
   
City   State/Province   Postal Code
   
 

Following/Attending Physician  
Last Name   First Name   MI
   
M.D.    D.O.      
First Specialty   Second Specialty
 

Telephone Number   Fax Number
( )   ( )
Address Line 1  
   
Address Line 2  
   
Address Line 3  
   
City   State/Province   Postal Code
   
 


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

Drug Indicated
Morphine   Baclofen   Floxuridene
Other    

Calibration Constant/Flow Rate
mg/ml  

Diagnostic Indication for Use
Malignant Pain
Type of Cancer

Primary site of pain:
Spine/Back
Abdominal/Visceral
Thoracic
Extremity
Head/Neck
Pelvic
Other

  Non-Malignant Pain
Cause:
Failed Back Syndrome
RSD/Causalgia (CRPS)
Osteoporosis
Joint Pain/Arthritis
Post-Herpetic Neuralgia
Peripheral Neuropathy
Other
Intractible Spasticity   Cancer Chemotherapy
Cause:
Cerebral Palsy
Brain Injury
Multiple Sclerosis
Spinal Cord Injury/Disease
Other
 
Type of Cancer:
Liver, Metastatic or Primary
Renal Cell
Prostate
Other

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

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

Catheter Implant Position
Intrathecal
Arterial
Epidural
Venous
Other
   

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

The information above marked in yellow is not required for registration.

To complete this registration, press the confirm button below.

Medtronic.com will then display a printable version of the registration received. Please print this for your records.

 
 

 

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