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 three 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. SRS and SBRT phantoms will also be sent out with high priority. 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:*
   

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) 792-3233 if you have any questions or concerns about your order.