US Oncology Phantom Request Form
INSTRUCTIONS:
All orders must be sumitted via this online form. Once you have submitted this form, Once you have submitted this form, please email Trang Nguyen (
trangnguyen@mdanderson.org
) to schedule the phantom. Please note that there are a finite number of phantoms and phantoms are intended to be irradiated over the course of the
five
year contract period. Prioritization will be based on first-come first-served as well as pressing clinical situations such as implementation of a new modality or a new linac. Trang will work with you to find a date to irradiate the phantom that works for you.
Please note you must return the phantom within 2 weeks of receiving it
- if you need to reschedule we are happy to accommodate, please just let us know before the phantom is shipped. .
*
Required Fields
*
Institution:
Physicist:
*
First Name:
*
Last Name:
*
Phone Number:
*
E-mail:
Address 1:
Address 2:
City:
State/Province:
Zip Code/Postal Code:
Country:
Phantom Requested:
*
IMRT H&N
HDR
SRS
Spine
Lung with motion
Lung without motion
Liver with motion
Liver without motion
IGRT
Small field single beam
Method of motion management
Treatment Machine:
Make:
Model:
Serial Number:
Photon Beam Energy to be Used:
Treatment Planning System:
Model:
Software Version:
Algorithm:
You will be contacted when your phantom is available for shipment, however, please feel free to contact us at (713) 745-8989 if you have any questions or concerns about your order.