Phantom Request Form For Protocol

Institution:
RTF No:   RTF Number?
Physicist first name:  
Physicist last name:    
Physicist phone number:    
Physicist email:      
Physician email to receive the report:  
Shipping to:
Address1:    
Address2:  
City:    
State/Province:    
Zip Code:    
Country  
Is the machine physically located at the address above?  
If "NO",
Address:  
Name of Facility:  
 
 Is this repeat phantom?
   
Phantom requested (Please select one):
   




Method to account for respiratory motion (if applicable):
 
Protocol to be credentialed for:    
Has your IRB granted approval for this protocol?  
Machine:    
  Make:  
  Model:  
  Serial number:  
  Photon/Proton beam energy to be used:  
If this is a new machine, please list all commissioned energies for this machine:    
   
     
Treatment planning system:
  Model  
  Software version:  
Algorithm used for
heterogeneity corrections:
 
Protons Only - Beam Delivery Method:
 
Nadia Hernandez or Hunter Mehrens will contact you when a phantom is available for shipment.  If you have any questions, please contact Nadia for H&N, spine or SRS and contact Hunter for liver or lung at 713-745-8989.