Atrotech Atrostim PNS Anwenderhandbuch Seite 118

IMPLANTED NERVE STIMULATOR
Registration Form A
IMPLANTATION DATE
Instructions:
This form will:
Ensure correct identification of implanted system with patient.
Provide information for implant records and proper patient follow-up.
Validate warranty agreement, if filled-in forms (A and B) are faxed to Atrotech.
HOSPITAL
IMPLANTING
SURGEON/
PHYSICIAN
PATIENT'S
NAME
CLINICAL
DIAGNOSIS
DEVICE
IDENTIFICATION
Keep original copy for physician/patient records.
Fax the filled-in form to Atrotech.
Address
City
Phone
Address
City
Phone
Patient Code No. (Hospital)
Home Address
City
Type of Device Implanted
Implant Stimulator Model
Serial No. (Left Side)
Electrode Model
Serial No. (Left Side)
Extension Lead Model
Serial No. (Left Side)
Stimulus Controller Model
Serial No.
ATROTECH Co.
P.O.Box 28
FIN-33721 TAMPERE
FINLAND
Phone +358 3 383 1300
Fax
Country
Fax
Country
Fax
Date of Birth
Country
Serial No. (Right Side)
Serial No. (Right Side)
Serial No. (Right Side)
+358 3 383 1324