Product Ordering

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

SIR-Spheres^® Y-90 resin microspheres North America Hospital Order Form

Hospital Name *

Account Number *

if you don't know your account number, email csusa@sirtex.com

Person Ordering *

Telephone *

E-mail *

Sirtex Representative’s email address

Additional Confirmation Recipient(s) (Please separate each email address with a Comma)

Treating Physician *

Delivery Information

Delivery Contact *

Telephone *

E-mail *

Treatment Address

Same as Delivery Address

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What's this?

Purchase Order Number

Patient ID (Do not include patient's name)

Referring Physician

Order Information

Order Deadline

Treatment Date *

Please click on calendar to select a date

Vials are delivered the day prior to treatment when possible, or in the early morning day of treatment.
Note: If you require the delivery the same day as the treatment date, please request this in the notes.

Quantity	Item	Vial Choice
Drop down (as is)	SIR-Spheres Y-90 resin microspheres SIR-Y002* 3ml vial	SELECTIVE
13 GBq Selective-7 DPC 10 GBq Selective – 6 DPC 8 GBq Selective – 5 DPC

HYBRID
6 GBq: Hybrid-4 DPC 5 GBq: Hybrid-3 DPC

COVERAGE
3.6 GBq: Coverage 2 DPC 2.8 GBq: Coverage 1 DPC 2.1 GBq Coverage Day of Calibration

*Activities noted are at 12am EST and rounded to the closest GBq

Click here to view the detailed Activity chart

Quantity	Item Number	Item
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-Y002 3mL vial	SIR-Spheres Y-90 resin microspheres Each SIR-Y002 includes one (1) SIROS D-Vial Prep Set and one (1) SIROS Delivery Set 7 day pre-calibration (13 GBq) 6 day pre-calibration (10 GBq) 5 day pre-calibration (8 GBq) 4 day pre-calibration (6 GBq) 3 day pre-calibration (5 GBq) 2 day pre-calibration (3.6 GBq) 1 day pre-calibration (2.8 GBq)
	SIR-K002	Accessories Pack (includes 1 Delivery Set, 1 V-Vial and 1 V-Vial Holder)
	SIR-V001	V-Vial
	SIR-D001	Delivery Set
	SIR-B001	Delivery Box
	SIR-10100	SIROS Delivery Dome
	SIR-10200	SIROS D-Vial Prep Set
	SIR-10300	SIROS Delivery Set
	SIR-S001	Syringe Shield
	SIR-H001	V-Vial Holder
	SIR-Y001 5mL vial	SIR-Spheres Y-90 resin microspheres Each SIR-Y001 includes one (1) SIROS D-Vial Prep Set and one (1) SIROS Delivery Set 4 day pre-calibration (9.44 GBq) 3 day pre-calibration (7.28 GBq) 2 day pre-calibration (5.62 GBq) 1 day pre-calibration (4.33 GBq*)

* Each SIR-Y001 includes: an accessories pack SIR-K002 (ONE (1) Delivery Set, ONE (1) V-Vial, ONE (1) V-Vial Holder) and shipping

SIR-Spheres Y-90 resin microspheres (including 1 each SIROS D-Vial Prep Set and SIROS Delivery Set)

Notes

Comments
(Do not include patient's name or other personally identifying information)

By submitting this order, I confirm I have reviewed and agree to the SIR-Spheres Terms and Conditions. To view Terms and Conditions, click here

* mandatory field

Caution: Federal (USA) law restricts this device to sale by or on the order of a physician. Indications for Use: SIR-Spheres^® Y-90 resin microspheres are indicated for the treatment of unresectable metastatic liver tumors from primary colorectal cancer with adjuvant intrahepatic artery chemotherapy (IHAC) of FUDR (Floxuridine). Side Effects: Common side effects are fever, transient decrease of hemoglobin, mild to moderate abnormality of liver function tests, abdominal pain, nausea, vomiting, and diarrhea. Potential serious effects due to exposure to high radiation include acute pancreatitis, radiation pneumonitis, acute gastritis, radiation hepatitis, and acute cholecystitis. Consult the Instructions for Use for a complete listing of indications, contraindications, side effects, warnings, and precautions.