IROC HOUSTON'S EXTERNAL BEAM DOSIMETRY SUMMARY FORM

Institution Name:*

Physicist/Dosimetrist First Name:*

Last Name:*

Physicist/Dosimetrist e-mail address:*

Radiation Oncologist First Name:*

Last Name:*

Radiation Oncologist e-mail address:*

Protocol #:*

RTF#(look up here):*

RTOG

NSABP

GOG

NCCTG

ANZGOG

TACO

Case #*

Patient initials:*

DOSE PRESCRIPTION

Please complete a new external beam dosimetry form for each prescription (i.e. pelvic script, boost script,extended field script, etc...)

Dose Prescription:*

cGy,

Number of Fractions*

Treatment Machine Model & SN*

Radiation Therapy Start Date:

Radiation Therapy End Date:

TREATMENT TECHNIQUE