Request for Information

Client Information

I would like to know more about



Product type included in this validation (please choose all that apply)





Please confirm the best way for DSI to follow-up with you:



Thank you for completing this form. If you are able to answer the additional questions further below, please continue without submitting the form at this point. Otherwise click the "Submit" button directly below and and DSI will contact you soon to gather additional information.

If product information is known, please provide additional information for this validation (choose all that apply):

Implantable telemetry



JET (Jacketed External Telemetry)


Ponemah software options





Video (specify in box provided below)


New System Validation

please provide the following information if known:

  1. All software [including version(s)] along with any service packs (SPs) you plan to include in this validation
  2. All existing hardware, JET, video, VivaMARS and implant types you already own [would not appear on the new system quote (if applicable)] that you plan to include in this validation
e.g. v5.2 SP7 PhysioTel Digital

Upgrade/Change Control

 please provide the following if known:
  1. All applicable software [including version(s)] along with any service packs (SPs) that were previously validated
  2. All applicable hardware, JET, video, VivaMARS and implant types that were previously validated
  3. The year the previous validation was completed
  4. The organization that performed the previous validation
  5. All software [including version(s)] along with any service packs (SPs) you plan to include in this validation
  6. All existing hardware, JET, video, VivaMARS and implant types you already own that you plan to include in this validation
  7. Any new hardware,  JET, video, VivaMARS and implant types you plan to include in this validation

e.g. v5.2 SP7 PhysioTel Digital

In the area below, please describe any additional information that might be important or helpful for DSI to understand to ensure an efficient and successful validation

(anticipated schedule, current vs desired state, any other potentially unique situations that will need to be taken into account, etc.)