Procedure Scheduling form Procedure Scheduling Form Procedure Scheduling Form Name First Last MRN*PROCEDUREAF AblationEP StudySVTAtrial Flutter AblationAtypical Flutter AblationAtrial TachycardiaPVCIdiopathic VTIschemic VTNon Ischemic VTAV Node AblationTEEDCCVTILT TABLENuclear (Treadmill)Nuclear (Lexiscan)MEDICATION- SOTALOLMEDICATION- SOTALOLSINGLE/DUAL PACEMAKERBIV PMPM GEN CHANGESINGLE/DUAL ICDBiV ICDUpgrade of PM to single/dual ICDUpgrade of PM to BiV ICDUpgrade of ICD to DualUpgrade to BiV ICDAtrial Lead revisionRV lead revisionLV lead revisionICD lead revisionOTHEROther Instructions & CommentsPhoneThis field is for validation purposes and should be left unchanged.