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Phantom Request


To save time completing this request form, existing users can log in to the User Portal here.

If you don't have portal access but your insitution has an RTF number, click here

(this will prepopulate much of the form data from your institution)

RTF No
Request Type
Phantom Requested
Using the control key while highlighting phantoms allows a request for more than one phantom type.
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)
Address
Name of Facility
Is this repeat phantom? (y/n)
Method to account for respiratory motion (if applicable)
Protocol to be credentialed for
Has your IRB granted approval for this protocol? (y/n)

Machine

Is this a new machine?
Machine
Machine Serial Number
Beam
If this is a new machine please list all energies (photon and electron) for this machine

Treatment Planning System

Model
Software Version
Algorithm used for
heterogeneity corrections

Misc

Protons Only - Beam Delivery Method
How did you hear of our services
If Other please indicate

Billing

Payment Type
Name
Title
Phone
Email
Department
Street Address
City
State
Zip code / postal code
Country

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Institution Name
RTF
City
State/Provence
Zip
Country

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