Sirtex - North America Online Order Form

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North America Online Order Form

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 American Hospital Order Form

Hospital Name

Account Number

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

Person Ordering

Telephone

E-mail

Additional Confirmation Recipient(s)

Please separate each email address with a comma and a space

Treating Physician

Delivery Address

Delivery Contact

Telephone

E-mail

Treatment Site Address

Same as Delivery Address

Save information above in a cookie for 90 days.

What's this?

Purchase Order Number

Patient ID

Referring Physician

Is the patient approved by insurance?

Yes No

Is the patient Bilirubin below 2.0 ml/d?

Yes No

Requested Delivery Date

Deadlines

Treatment Date

Delivery Day	Monday	Tuesday	Wednesday	Thursday	Friday
# Days pre-cal	3 day (Thursday) 7.28 GBq	3 day (Friday) 7.28 GBq	3 day (Saturday) 7.28 GBq	3 day (Sunday) 7.28 GBq	3 day (Monday) 7.28 GBq
	2 day (Wednesday) 5.62 GBq	2 day (Thursday) 5.62 GBq	2 day (Friday) 5.62 GBq	2 day (Saturday) 5.62 GBq	2 day (Sunday) 5.62 GBq
	1 day (Tuesday) 4.33 GBq	1 day (Wednesday) 4.33 GBq	1 day (Thursday) 4.33 GBq	1 day (Friday) 4.33 GBq	1 day (Saturday) 4.33 GBq

Quantity	Item Number	Item
	SIR-Y001*	SIR-Spheres Y-90 resin microspheres 3 day pre-calibration (7.28 GBq) 2 day pre-calibration (5.62 GBq) 1 day pre-calibration (4.33 GBq) All activity is based upon 8 AM ET delivery. Refer to SIR-Spheres Y-90 resin microspheres Dose Calibration and Delivery Schedule. Please refer to video link for activity and calibration choice. Please select either Yes or No below. 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 1 Delivery Set, 1 V-Vial and 1 V-Vial Holder)
	SIR-V001	V-Vial
	SIR-D001	Delivery Set
	SIR-H001	V-Vial Holder
	SIR-S001	Syringe Shield
	SIR-B001	Delivery Box
	SIR-10100	SIROS Delivery Dome
	SIR-10200	SIROS D-Vial Prep Set
	SIR-10300	SIROS Delivery Set

Comments

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. Thank you for your order. We appreciate your business.

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

Form 910E
Reference: QSOP06
200-U-0619
Revision #7 (CR2549) 12 September 2019

CAUTION: Federal law restricts this device to sale by or on the order of a physician or licensed healthcare practitioner.

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

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