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 *

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

Treating Physician *

Delivery Information

Delivery Address *

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

Is the patient approved by insurance?

Yes No

Is the patient Bilirubin below 2.0 ml/d?

Yes No

Order Information

Order Deadline

Requested Delivery Date *

Please click on calendar to select a date

Treatment Date *

Please click on calendar to select a date

Product Code	SIR-Y002 All Vial Options available for delivery Monday - Friday
SIR-Y002 (3mL Vial)	7.34 GBq (Vial Activity) 5-DPC (Days Pre-Calibrated Delivered)
	5.66 GBq (Vial Activity) 4 - DPC (Days Pre-Calibrated Delivered)
	4.37 GBq (Vial Activity 3- DPC (Days Pre-Calibrated Delivered)
	3.37 GBq (Vial Activity) 2 - DPC (Days Pre-Calibrated Delivered)
	2.60 GBq (Vial Activity) 1 - DPC (Days Pre-Calibrated Delivered)
	1.96 GBq (Vial Activity) Day of Calibration
Product Code	SIR-Y001 All Vial Options available for delivery Monday - Friday
SIR-Y001 (5mL Vial)	9.4 GBq (Vial Activity) 4 - DPC (Days Pre-Calibrated Delivered)
	7.28 GBq (Vial Activity 3- DPC (Days Pre-Calibrated Delivered)
	5.62 GBq (Vial Activity) 2 - DPC (Days Pre-Calibrated Delivered)
	4.33 GBq (Vial Activity) 1 - DPC (Days Pre-Calibrated Delivered)
	SIR-Y002 vial activity listed is calibrated for 8am EST SIR-Y002 (3mL) vials are ~27.3 million spheres per vial SIR-Y002 Calibrates at 1.8 GBq 6pm EST SIR-Y001 (5mL) vials are ~ 44 million Spheres per vial SIR-Y001 Calibrates at 3 GBq 6pm EST SIR-Y001 have a standard deviation of 2.6 million spheres per vial

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*	SIR-Spheres Y-90 resin microspheres Each SIR-Y002 includes one (1) SIROS D-Vial Prep Set and one (1) SIROS Delivery Set 5 day pre-calibration (7.34 GBq) 4 day pre-calibration (5.66 GBq) 3 day pre-calibration (4.37 GBq) 2 day pre-calibration (3.37 GBq) 1 day pre-calibration (2.60 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*	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

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

Form 910e
Reference: QSOP06
200-U-0619

Revision #8 (CR3139) 12 December 2022

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). Consult the Instructions for Use for a complete listing of indications, contraindications, side effects, warnings, and precautions.