Product Ordering

Rest of Asia Order Form

Thank you for using the Sirtex Online Order Form. Please complete the fields below to place your order. After the order has been processed, you will receive an order confirmation from Customer Service. If you have any questions, please email csapac@sirtex.com or call us on one of our numbers listed on our Contact page.

SIR-Spheres^® Y-90 resin microspheres Order Form - Rest of Asia Pacific (Excluding Australia)

(Note: * denotes required field)

Hospital Name*

Account Number *

(if you don't know your account number, email csapac@sirtex.com)

Person Ordering *

Telephone * Please state country code

E-mail *

Additional Confirmation Recipient(s) Please separate each email address with a comma and a space

Delivery Information

Contact Person*

Delivery Address*

Telephone* Please state country code

E-mail

Treatment Site Information

Same as Hospital Name

Treatment Site Name*

Account Number *

(if you don't know your account number, email csapac@sirtex.com)

Same as Delivery Address

Treatment Site Address*

Contact Person*

Billing Address Information

Same as Treatment Site Address

Billing Address*

Save information above in a cookie for 90 days.

What's this?

Treating Physician Information

Treating Physician Name *

Treating Physician Specialty

Treating Physician Name

Treating Physician Specialty

Add another

Referring Physician

Purchase Order Number

Patient ID

Purchase Order

Tumour Type*

Activity at calibration day/date is 3Gbq (± 10%) at AEST 09:00:00hrs.

Calibration Date

Treatment Date

Requested Delivery Date

(?) Deadlines

MAA Date

Warning! The selected delivery date is prior to the first available delivery date: . Please call Customer Service.

Quantity	Item Number	Item
	SIR-Y001	SIR-Spheres Y-90 resin microspheres (including 1 Accessories Pack) SIR-Spheres Y-90 resin microspheres (including 1 SIROS D-Vial Prep Set & 1 SIROS Delivery Set) Has the treating physician listed been trained by a SIRTEX representative in proper handling and use of SIR-Spheres resin microspheres and accessories? Yes No Would you like to treat the patient using the SIROS supplies? Yes No
	SIR-K002	Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	V-Vial
	SIR-D001 BOXED	Delivery Set
	SIR-S001	Syringe Shield
	SIR-B001 BOXED	Delivery Box
	-	Other, please specify:
	SIR-10100	SIROS Delivery Dome
	SIR-10200	SIROS D-Vial Prep Set
	SIR-10300	SIROS Delivery Set
	SIR-H001	V-Vial Holder

Notes

Comments

Submission of this order form constitutes acceptance and consent to adhere to the Sirtex Order and Cancellation Policy. Customer acknowledges that all required steps have been performed prior to ordering (i.e. insurance approval, lab work, etc.). Submission also constitutes that all parties have appropriate licensing in place to handle our product.

* mandatory field

SIR-Spheres^® is a registered trademark of Sirtex SIR-Spheres Pty Ltd.

Form 900e
Reference: QSOP06
APM-AP-006-05-23

Revision #04 (CR3863) 10 Apr 2025