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Date of birth of person injured
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Which Guidant cardiac defibrillator was implanted?
Ventak Prizm AVT
Prizm 2 DR
Contak Renewal
Contak Renewal 2
Vitality AVT
Renewal 3 AVT
Renewal 4 AVT ICD
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Don't know

If other, what is the name of the defibrillator that was implanted?

Date the device was implanted:

Is the device still implanted?
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What medical condition prompted the use of the device?

Please describe any problems or injuries caused by the device:

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