Phantom Request Form

Phantom Request Form

Institution:

RTF No:

RTF Number?

Physicist:

First name:

Last name:

Phone number:

Email:

Address1:

Address2:

City:

State/Province

Zip Code

Country

Phantom requested (please check one):

SRS head

IMRT H&N

IMRT prostate

IMRT/3DCRT thorax

SBRT thorax

SBRT liver

Spine

	Method to account for respiratory motion (if applicable):

Protocol to be credentialed for:

Has your IRB granted approval for this protocol?:

Does your institution have an ITC account?

Machine:

Make:

Model:

Serial number:

Photon beam energy to be used:

Treatment planning system:

model

software version:

algorithm used for heterogeneity corrections:

Nadia Hernandez or Carrie Amador will contact you when a phantom is available for shipment. If you have any questions, please contact Nadia for H&N, liver, spine or SRS or Carrie for prostate or lung at 713-745-8989.