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Phantom Request


How many different machines do you want phantoms for?
RTF No
Request Type

Machine 1

Phantom Requested
Using the control key while highlighting phantoms allows a request for more than one phantom type.
* indicated a phantom that could be requested for expedited processing.
Typically, phantom results are available 5-6 weeks after the date of the phantom irradiation. We now offer a service that will expedite this process to 3 weeks after the irradiation, as long as all plan data is accurately submitted. The price of the expedited service is $500 more than the typical phantom price. Would you like to order expedited service for a fee of $500?
Is this a new machine?
If New Machine - Enter Name
Machine Serial Number
If this is a new machine please list all energies (photon and electron) for this machine.
Comments on Beam Selection

Machine 2

Phantom Requested
Using the control key while highlighting phantoms allows a request for more than one phantom type.
* indicated a phantom that could be requested for expedited processing.
Typically, phantom results are available 5-6 weeks after the date of the phantom irradiation. We now offer a service that will expedite this process to 3 weeks after the irradiation, as long as all plan data is accurately submitted. The price of the expedited service is $500 more than the typical phantom price. Would you like to order expedited service for a fee of $500?
Is this a new machine?
If New Machine - Enter Name
Machine Serial Number
If this is a new machine please list all energies (photon and electron) for this machine.
Comments on Beam Selection

Machine 3

Phantom Requested
Using the control key while highlighting phantoms allows a request for more than one phantom type.
* indicated a phantom that could be requested for expedited processing.
Typically, phantom results are available 5-6 weeks after the date of the phantom irradiation. We now offer a service that will expedite this process to 3 weeks after the irradiation, as long as all plan data is accurately submitted. The price of the expedited service is $500 more than the typical phantom price. Would you like to order expedited service for a fee of $500?
Is this a new machine?
If New Machine - Enter Name
Machine Serial Number
If this is a new machine please list all energies (photon and electron) for this machine.
Comments on Beam Selection

Machine 4

Phantom Requested
Using the control key while highlighting phantoms allows a request for more than one phantom type.
* indicated a phantom that could be requested for expedited processing.
Typically, phantom results are available 5-6 weeks after the date of the phantom irradiation. We now offer a service that will expedite this process to 3 weeks after the irradiation, as long as all plan data is accurately submitted. The price of the expedited service is $500 more than the typical phantom price. Would you like to order expedited service for a fee of $500?
Is this a new machine?
If New Machine - Enter Name
Machine Serial Number
If this is a new machine please list all energies (photon and electron) for this machine.
Comments on Beam Selection
IF this is a small field single beam please enter the cone size
Typically, phantom results are available 5-6 weeks after the date of the phantom irradiation... Would you like to order expedited service for a fee of $500?
Voucher #

Demographics

Institution
Physicist first name
Physicist last name
Physicist phone number
Physicist email

Shipping To

Department
Street Address
City
State/Province
Zip Code:
Country
Is the machine physically located at the address above? (y/n)
Machine Address
Name of Facility
Method to account for respiratory motion
Protocol to be credentialed for

Treatment Planning System

Model
Software Version
Algorithm used

Billing

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Title
Phone
Email
Street Address
City
State
Zip code

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