Phantom Request Form For Protocol
Physicist first name:
Physicist last name:
Physicist phone number:
Physician email to receive the report:
Is the machine physically located at the address above?
Name of Facility:
Is this repeat phantom?
Phantom requested (Please select one):
3D CRT Thorax
Proton IGRT Phantom
Proton CT-RLSP Phantom
Method to account for respiratory motion (if applicable):
Protocol to be credentialed for:
Has your IRB granted approval for this protocol?
Photon/Proton beam energy to be used:
If this is a new machine, please list all commissioned energies for this machine:
Treatment planning system:
Algorithm used for
Protons Only - Beam Delivery Method:
If you have any questions, please contact Nadia Hernandez or Andrea Molineu at 713-745-8989.