Generator Implant Data

Date of Report (mo/day/yr):

1. ID Number :
2. Institution:
3. Sequence Number of this Generator:
4. Implant Date (mo/da/yr):
5. Manufacturer:
6. Model Number:
7. Generator Serial Number:

8. Programmed Generator Settings when Patient Was Discharged:

Mode: AV Interval: Rate Response Curve:

Rate: Upper Rate Limit: Hysteresis:

Select Generator Polarity


               Ventricle   Atrium

Pulse Amplitude: ------- --------

Pulse Width: ----------- ------

Sensitivity: -------------- ------

Refrac. Period: --------- --------

9. Comments

Your Name:

Your E-Mail Address:

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