Appendix B: Mri-Cs Eligibility Form; Medtronic Neurostimulation System Mri-Cs Scan Eligibility - Medtronic 97702 Instrucciones De Uso

Appendix B: MRI-CS Eligibility Form

Medtronic Neurostimulation System MRI-CS Scan Eligibility

At the time of the MRI appointment:
1. See labeling for safety conditions: www.medtronic.com/mri.
2. Confirm that stimulation is off prior to the MRI scan.
Patient name:
Physician name, office, address,
and phone number:
Important: Use the MRI conditionally safe (MRI-CS) mode on the clinician programmer
or patient control device to enter the information and scan eligibility result below.
Date and time eligibility was
determined:
Information code:
Neurostimulator model
number:
The neurostimulation system MRI-CS eligibility cannot be
(not applicable for MRI-CS FULL BODY SCAN ELIGIBLE)
MRI guidelines for Medtronic neurostimulation systems for chronic pain English 27
MRI-CS FULL BODY SCAN ELIGIBLE
MRI-CS HEAD SCAN ELIGIBLE WITH
TRANSMIT/RECEIVE HEAD COIL
determined.
Neurostimulator serial
number: