Product Ordering

Online Order Form - Europe and Israel

Thank you for using the Sirtex Online Order Form.

Please complete the fields below to place your order. By entering your account number, you will be able to see the delivery options available for your center.

After your order has been processed, you will receive an order confirmation from Customer Service.

Cancellation Policy: If your order of SIR-Spheres^® Y-90 resin microspheres needs to be canceled after order deadline, please advise Sirtex Customer Service as soon as possible by email at cs-eu@sirtex.com.

Receipt of your cancellation will be confirmed by Sirtex.

If you have any questions or do not know your account number, please email cs-eu@sirtex.com or call us at +49-228-1840-730.

SIR-Spheres^® Y-90 resin microspheres Online Order Form - Europe and Israel

Person Ordering *

Telephone *

Email *

Account Number *

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

Distributor Information (if applicable)

Distributor Name

Phone

Delivery Information

Contact Name *

Address *

Postcode

City *

Country *

Save information above in a cookie for 90 days.

(The values you enter above will be saved to a cookie in your web browser. The information will automatically expire after 90 days.)

Treatment Site Information

Hospital Name *

Treating Physician (only Sirtex TEC certified)*

Address Same as Delivery Address

Postcode

City

Country

Phone

OMT (Order Map and Treat)*

Yes No

FLEXdose Delivery Programme Options

(Refer to SIR-Spheres Y-90 resin microspheres Dose Calibration and Delivery Schedule here)

Delivery Date

Treatment Date

(Note: Please make sure delivery date, calibration option and treatment date are selected)

Order Information

Purchase Order Number

Patient ID

Attention! The selected delivery date is prior to the first available delivery date: . Please modify the date or contact Customer Service for availability.

Quantity	Item Number	Item
	SIR-Y001	SIR-Spheres® Y-90 resin microspheres (Standard activity per dose: 3 GBq +/- 10% at day of calibration 23:00 GMT) 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 Delivery System? Yes No (Note: one (1) SIROS^TM Delivery Set (SIR-10300) + one (1) SIROS^TM D-Vial Prep Set (SIR-10200) are included with each SIR_Spheres dose)
	SIR-K002	Gen 1 Accessories Pack (Gen 1 Delivery Set, Gen 1 V-Vial and Gen 1 V-Vial Holder)
	SIR-S001	Syringe Shield Reuseable item: Please state reason for ordering
	SIR-B001	Gen 1 Delivery Box Reuseable item: Please state reason for ordering
	SIR-10100	SIROS^TM Delivery Dome Reuseable item: Please state reason for ordering
	SIR-10200	SIROS^TM D-Vial Prep Set Shipped seperately from SIR-Spheres dose
	SIR-10300	SIROS^TM Delivery Set Shipped seperately from SIR-Spheres dose
	SIR-H001	V-Vial Holder

Treated Disease

Notes

Comments

Submission of this order form constitutes acceptance and consent to adhere to the Sirtex Order and Cancellation Policy.

Customer acknowledges that all licensing is in place and all required steps have been performed prior to ordering, including signing the Agreement on the Protection of Patient Information.

* mandatory field

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

Form 915e
Reference: QSOP06
280-E-1019

Revision # 0 (CR 2579) Issued 05 Nov 2019