Sirtex - Online Cancellation Form

CANCELLATION FORM : SIR-Spheres^® Y-90 resin microspheres

Contact Name *

Phone *

Email *

Multiple entries allowed. Please separate each email address with a comma and a space

Distributor Name (if applicable)

Treatment Site Information

Site Name *

Address/City

Country

Cancellation information

Quantity of doses to cancel

Sirtex Order Confirmation number*

Cancellation date*

Work-up date*

OMT

Another treatment planned

Date of scheduled treatment

Reasons for cancellation

Medical indications

Excessive lung shunt (≥30 Gy)

ECOG status >2

Ascites or clinical liver failure

Progressive disease

Patient deceased

Severely compromised liver function

Markedly abnormal synthetic and excretory liver function tests

Pre-assessment angiogram that demonstrates abnormal vascular anatomy that would result in significant reflux of hepatic arterial blood to the stomach, pancreas or bowel

Other contra-indication, please specify

Other reasons

Patient insurance issues

Patient cancelled treatment / unable to make appointment

Administrative issues, please specify

Logistical issues, please specify

Other, please specify

* mandatory field

Instructions

If your order of SIR-Spheres^® Y-90 resin microspheres needs to be cancelled after the indicated order deadline on the order form, please complete this Cancellation Form
Customer Service will confirm receipt by e-mail
File(s) to be saved by Customer Service

Online Cancellation Form