SureScan Online Form

Patient Name
Date of Birth
MM slash DD slash YYYY
1. Your Patient has an MRI Ordered. Please confirm that your patient has a SureScan Pacing System (Advisa MRI SureScan IPG Model: A2DR01 or Revo MRI SureScan IPG Model: RVDR01 and CapSureFix MRI SureScan leads Model: 5086MRI*
- YES, my patient has a complete SureScan Pacing System and it has been implanted longer than 6 weeks in the pectoral region.
- NO, my patient does not have a complete SureScan System.
- DOO Pacing Rate:
bpm

bpm
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- AOO Pacing Rate:
bpm

bpm
- Voo Pacing Rate:
bpm

bpm
Untitled
- ODO Pacing Rate: OFF
Physician Signature
Physician Name
Date
MM slash DD slash YYYY
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