IRF {Serial/Lot Number}  
Receiver Model Number   Serial/Lot Number Date of Implant
{filled in by server}   {filled in by server}
IRF Manufacturer
Extension Model Number   Serial/Lot Number  
   
Transmitter Model Number   Serial/Lot Number  
   

Diagnostic Reason
Arachnoiditis
 
Peripheral Causalgia
 
Peripheral Neuropathy
 
Post-Herpetic Neuralgia
Failed Back Surgery Syndrome
 
Phantom Limb/Stump Pain
 
Ischemic Peripheral Pain
 
Other Chronic, intractable, pain of trunk or limbs

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

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