Phantom Request Form For Protocol
Institution:
RTF No:
RTF Number?
Physicist first name:
Physicist last name:
Physicist phone number:
Physicist email:
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
Phantom requested (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
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.