Product Ordering

Online Order Form - Middle-East and Africa

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 cancelled 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 - Middle East and Africa

Person Ordering *

Telephone *

Email *

Account Number *

Delivery Information

Contact Name *

Address *

Postcode

City *

Country *

Treatment Site Information

Site Name *

Treating Physician *

Address Same as Delivery Address

Postcode

City

Country

Phone

Distributor Information

Distributor Name

Phone

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.)

Order Information

Purchase Order Number

Patient ID

(Flexdose order deadline Tuesdays 4pm CET the preceding week. Regular dose order deadline Wednesdays 4pm CET the preceding week.)

Requested Calibration Date

Flight Arrival Date

Scheduled Treatment Date

Order Deadline	Flight Day	Arrive Day	Calibration Day	Pre-Calibration Activity (assuming one day Customs clearance)	Treatment Day
Tuesday 4pm CET	Friday	Saturday	Tuesday	2 days 1 day 0 day +1 day	Sunday Monday Tuesday Wednesday
	Saturday	Sunday	Wednesday	2 days 1 day 0 day +1 day	Monday Tuesday Wednesday Thursday
	Sunday	Monday	Thursday	2 days 1 day 0 day +1 day	Tuesday Wednesday Thursday Friday

Quantity	Item Number	Item
	SIR-Y001	SIR-Spheres Y-90 resin microspheres Each dose may include a maximum of two (2) accessory packs (SIR-K002) which contains one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder. Please order accordingly, Refer to SIR-Spheres Y-90 resin microspheres Dose Calibration and Delivery Schedule 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 Accessory Pack (Gen 1 Delivery Set, Gen 1 V-Vial and Gen 1 V-Vial Holder) Max. two (2) packs per dose
	SIR-S001	Syringe Shield Reuseable item: Please state reason for ordering
	SIR-B001	Gen 1 Delivery Box Reuseable item: Please state reason for ordering
	-	Other, please specify:
	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

Please Specify

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