Sirtex - APAC Online Order Form

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

SIR-Spheres^® Y-90 resin microspheres Order Form - Australia

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

Delivery Information

Note: For distributors, please fill in your distributor's address. For all Singapore hospitals, please fill in the delivery address of the hospital

Treatment Site Information

Same as Hospital Name

Same as Delivery Address

Treatment Site Address*

Contact Person*

Billing Address Information

Treating Physician Information

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

Calibration Date

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

Item Number	Item
SIR-Y001	SIR-Spheres Y-90 resin microspheres SIR-Spheres Y-90 resin microspheres (including 1 Accessories Pack) 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

Payment Type*

Bill To:	SIR-Spheres Y-90 resin microspheres (including 1 free Accessories Pack) Amount (excl. GST)	Additional accessories pack (please select 1 billing party)
Hospital
Patient Name* Nominated Contact* Telephone* E-mail*	Patient consent received*
Total (excl. GST)	$0.00

Notes

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.

Product Ordering

APAC Online Order Form

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

SIR-Spheres® Y-90 resin microspheres Order Form - Australia