Right Side; Left Side - Atrotech Atrostim PNS Anwenderhandbuch

IMPLANTED NERVE STIMULATOR
Registration Form B
IMPLANTATION DATE
Instructions:
Use these symbols:

RIGHT SIDE

TICK ELECTRODE POSITION
CRANIAL
CRANIAL
DISTAL
DISTAL
CRANIAL
CRANIAL
DISTAL DISTAL
PATIENT
Complete the sites of implant stimulators, connectors and
electrode matrices on both sides (drawing below).
Keep original copy for physician/patient records.
Fax the filled-in form to Atrotech.
1 = IMPLANT STIMULATOR
2 = CONNECTORS
= ELECTRODE
ATROTECH Co.
P.O.Box 28
FIN-33721 TAMPERE
FINLAND
Phone +358 3 383 1300
Fax
(Pay attention to the location of the cut corner!)

LEFT SIDE

TICK ELECTRODE POSITION
1
CRANIAL
2 DISTAL
CRANIAL
3
DISTAL
4
5
6
7
8
9
10
11
+358 3 383 1324
CRANIAL
DISTAL
CRANIAL
DISTAL