IPG {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}

Diagnostic Indication for Use
Essential Tremor
Parkinsonian Tremor
Other
   

Implant Position
Left
 
Right
       

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