Appendix A; Boston Scientific Dbs Systems Mri Full Body Patient Eligibility Form - Boston Scientific ImageReady MRI Mode D'emploi

Appendix A

Appendix A

Boston Scientific DBS Systems MRI Full Body Patient Eligibility Form

This form provides information about the patient's implanted DBS System MRI scan eligibility. It may be
provided to the radiologist to support the confirmation of the patient's MRI scan eligibility.
Patient Name
Physician Name
Office Address
Phone
A. MR Conditional DBS System Information
Leads and Accessories (check all that apply)
30 cm Lead
45 cm Lead
Vercise Cartesia 30 cm 8 Contact DBS Directional Lead
Vercise Cartesia 45 cm 8 Contact DBS Directional Lead
Lead Boot
Silicone Suture Sleeves
Fixation (Check all that apply)
Burr Hole Cover
Other (List other implanted components)
Note: If the patient has medical implants from another manufacturer, consult the instructions from the manufacturer before
making a decision about MRI eligibility.
ImageReady™ MRI Guidelines for Boston Scientific Deep Brain Stimulation Systems
91098813-02 Rev C 10 of 277
Date:
Model # MRI
Eligible
□
DB-2201-30-AC
□
DB-2201-30-DC
□
DB-2201-45-AC
□
DB-2201-45-DC
□
DB-2202-30
□
DB-2202-45
□
Provided in Lead kit
□
Provided in
DB-2500-C kit
□
Provided in Lead kit
□
Provided in
DB-2500-C kit
□
DB-4600-C
□
DB-4605-C
□
□
Not MRI
Eligible
□
□