Braile Biomédica

Implants Registration - Heart Valves

Patient´s name (initials):

Birth date:

Procedure date:

Sex:

Weight (Kg):

Height (m):

Body surface (m2):

Doctor:

City:

State:

Country:

Medical agreement:

Distributor/Representative:

Prosthesis:

Size (mm):

Surgery:

Diagnosis:

Manufacturer and model

Previous implant date:

Serial number:

Note:

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