IPG {Serial/Lot Number}  
Implantable Pulse Generator
Model Number
  Date of Implant
{filled in by server}    
IPG Manufacturer

Extensions
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     

Diagnostic Indication for Use
Sacral Nerve Stimulation for Urinary Dysfunction
Sacral Nerve Stimulation for Bowel Dysfunction
Dynamic Graciloplasty
Gastric Stimulation
Other
   

Previous Device 1 Data (Complete if the following information for devices being replaced)
IPG Model No.   IPG Serial No.   IPG Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date    
   

Previous Device 2 Data (Complete if the following information for devices being replaced)
IPG Model No.   IPG Serial No.   IPG Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date