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

Appendix A: MRI Patient Eligibility Form

Boston Scientific DBS Systems Full Body MRI 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:
Date:
Physician Name:
Office Address:
Phone:
A. Type of MR Conditional DBS System
Fully Implanted Lead-Only System
Externalized Lead-Only System
Vercise Genus Full System
Vercise Gevia Full System
B. MR Conditional System Components
Component
Leads: Standard Leads - DB-2201
30 cm Lead
45 cm Lead
Leads: Directional Leads - DB-2202
Vercise™ Cartesia™ 30 cm
8 Contact DBS Directional Lead
Vercise™ Cartesia™ 45 cm
8 Contact DBS Directional Lead
Extensions
55 cm 8 Contact Lead Extension
55 cm 2x8 Contact Lead Extension
95 cm 2x8 Contact Lead Extension
Stimulators
Vercise Gevia™ 16 Contact
Implantable Pulse Generator
Vercise Genus™ P8 Implantable
Pulse Generator
Vercise Genus™ P16 Implantable
Pulse Generator
Vercise Genus™ P32 Implantable
Pulse Generator
□
□
□
□
Fully
Model Number(s)
Implanted
Lead-Only
System
□
DB‑2201‑30‑AC
□
DB‑2201‑30‑DC
□
DB‑2201‑45‑BC
□
DB‑2201‑45‑DC
□
DB‑2202‑30
□
DB‑2202‑45
N/A
NM‑3138‑55
N/A
DB‑3128‑55
N/A
DB‑3128‑95
N/A
DB‑1200
N/A
DB‑1408
N/A
DB‑1416
N/A
DB‑1432
ImageReady™ MRI Guidelines for Boston Scientific Deep Brain Stimulation Systems
Appendix A: MRI Patient Eligibility Form
Eligible for MR Conditional Scan
Externalized
Vercise Genus
Lead-Only
Full System
System
□ □
□ □
□ □
□ □
□ □
□ □
□
N/A
□
N/A
□
N/A
N/A N/A
□
N/A
□
N/A
□
N/A
92328636-03
Vercise Gevia
Full System
□
□
□
□
□
□
□
N/A
N/A
□
N/A
N/A
N/A
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