Appendix A; Wavewriter Alpha Systems Imageready Mri Full Body Patient Eligibility - Boston Scientific WaveWriter Alpha Manual Del Usuario

Appendix A

Appendix A

WaveWriter Alpha Systems ImageReady MRI Full Body Patient Eligibility

This form provides information about the patient's implanted WaveWriter Alpha Spinal Cord Stimulator System and MRI scan
eligibility. It may be provided to the radiologist to support the confirmation of the patient's scan.
• Prior to performing an MRI Scan, confirm that an MRI mode is enabled on the Remote Control
• Refer to www.bostonscientific.com/imageready for labeling and safety conditions
Patient Name:
Physician Name,
Office, Address
Phone:
A. MR Conditional WaveWriter Alpha Systems Information
1. Implantable Pulse Generator (IPG)
• WaveWriter Alpha 16 Contact IPG
• WaveWriter Alpha 32 Contact IPG
• WaveWriter Alpha Prime 16 Contact IPG
• WaveWriter Alpha Prime 32 Contact IPG
NOTE: If you have another model number IPG, please refer to the labeling specific to your IPG model number.
2. Percutaneous and/or surgical paddle leads (check all that apply)
• Avista MRI Percutaneous Lead, 8-contact Lead, 56 cm
• Avista MRI Percutaneous Lead, 8-contact Lead, 74 cm
• Linear™ Percutaneous Leads, 50 cm
• Linear Percutaneous Leads, 70 cm
• Linear ST Percutaneous Leads, 50 cm
• Linear ST Percutaneous Leads, 70 cm
• Linear 3-4 Percutaneous Leads, 50 cm
• Linear 3-4 Percutaneous Leads, 70 cm
• Linear 3-6 Percutaneous Leads, 50 cm
• Linear 3-6 Percutaneous Leads, 70 cm
• Infinion™ CX Percutaneous Leads, 50 cm
• Infinion CX Percutaneous Leads, 70 cm
• Artisan™ MRI Surgical Leads, 50 cm
• Artisan MRI Surgical Leads, 70 cm
• Artisan Surgical Leads, 50 cm
ImageReady™ MRI Full Body Guidelines for WaveWriter Alpha™ and WaveWriter Alpha™ Prime Spinal Cord Stimulator Systems
92395577-02 34 of 797
Date:
Model # MRI Not MRI
Full Body Eligible
Eligible
□
SC-1216
□
SC-1232
□
SC-1416
□
SC-1432
□
SC-2408-56
□
SC-2408-74
□
SC-2158-50
□
SC-2158-70
□
SC-2218-50
□
SC-2218-70
□
SC-2352-50
□
SC-2352-70
□
SC-2366-50
□
SC-2366-70
□
SC-2317-50
□
SC-2317-70
□
SC-8416-50
□
SC-8416-70
□
SC-8216-50