US Oncology Peer Review Service Registration Form

Linac being registered

*Serial number:

*Make:

*Model:

*Institution:

RTF no:

or IROC no:

if available

*Institution address:

if different

Billing address:

*City:

City:

*State:

State:

*Zip:

Zip:

*Contact physicist first name:

Billing contact first name:

*Contact physicist last name:

Billing contact last name:

*Contact physicist e-mail:

Wrong Email

Billing contact e-maill:

*Contact physicist phone:

Billing contact phone:

*Contact physicist phone: ?Billing contact phone:

*Package desired:

Basic ($1,667.00 / yr)

SBRT ($2,500.00 / yr)

SRS/SBRT ($2,833.00 / yr)

Additional Ir-192 HDR ($135/yr)

You will receive an invoice for your order.

Important details

The term is for 3 years, ending 12/31/2017.

Any result outside of criteria (phantom or OSLD check) will necessitate a repeat. The cost of this repeat is not included in the package price.

For questions, please contact Stephen Kry, Ph.D., E-mail to: Sfkry@MDAnderson.org