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Phantom Request
To save time completing this request form, existing users can log in to the User Portal
here.
Request Type
--Select Type--
Clinical Trial
Recalculation for Clinical Trial
For Fee
Recalculation for Fee
Varian
RTOG Foundation
US Oncology
Phantom Requested
IMRT H and N
IMRT Spine
Liver Phantom WITH Motion Table
Liver Phantom WITHOUT Motion Table
Lung Phantom WITH Motion Table
Lung Phantom WITHOUT Motion Table
Proton Brain
Proton CT-RLSP Phantom
Proton H and N
Proton IGRT Phantom
Proton Liver WITH Motion Table
Proton Liver WITHOUT Motion Table
Proton Lung WITH Motion Table
Proton Lung WITHOUT Motion Table
Proton Output Check
Proton Prostate
Proton Spine
SRS Head
TBI Phantom
IMRT H and N
IMRT Spine
Liver Phantom WITH Motion Table
Liver Phantom WITHOUT Motion Table
Lung Phantom WITH Motion Table
Lung Phantom WITHOUT Motion Table
Proton Brain
Proton CT-RLSP Phantom
Proton H and N
Proton IGRT Phantom
Proton Liver WITH Motion Table
Proton Liver WITHOUT Motion Table
Proton Lung WITH Motion Table
Proton Lung WITHOUT Motion Table
Proton Output Check
Proton Prostate
Proton Spine
SRS Head
TBI Phantom
Using the control key while highlighting phantoms allows a request for more than one phantom type.
Voucher #
Demographics
Institution
RTF No
Physicist first name
Physicist last name
Physicist phone number
Physicist email
Shipping To
Address1
Address2
City
State/Province
Zip Code:
Country
Is the machine physically located at the address above? (y/n)
--Select Yes or No--
Yes
No
Address
Name of Facility
Is this repeat phantom? (y/n)
Yes
No
Method to account for respiratory motion (if applicable)
Protocol to be credentialed for
Has your IRB granted approval for this protocol? (y/n)
--Select Yes or No--
Yes
No
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
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