Phantom Request Form For Protocol

Institution: RTF No: ? RTF Number?

Physicist first name: ? Physicist last name: ?

Physicist phone number: ?

Physicist email: ? Please enter correct email address.

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? Yes No

If "NO",

Address:

Name of Facility:

Is this repeat phantom? Yes No Please select one.

Phantom requested (Please select one):

Please select one. SRS Head Proton H&N IMRT H&N Proton Thorax IMRT Thorax Proton Liver 3D CRT Thorax Proton Prostate IMRT Spine Proton Spine Photon Liver Proton IGRT Phantom TBI Phantom Proton CT-RLSP Phantom Proton Brain

Method to account for respiratory motion (if applicable):

Protocol to be credentialed for: ?

Has your IRB granted approval for this protocol? Yes No Please select one.

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:

If you have any questions, please contact Nadia Hernandez or Andrea Molineu at 713-745-8989.