Get Therasphere Order Form

The TheraSphere Order Form is a crucial document for initiating the order process for TheraSphere treatments. This guide will provide you with detailed instructions on how to effectively complete the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete and submit your TheraSphere Order Form online.

1. Click ‘Get Form’ button to obtain the TheraSphere Order Form and open it in the designated platform.
2. Fill in the 'Site Name' and 'Location Identifier'. These fields should identify the treatment facility and its specific location.
3. Insert the 'Contact Name' of the person responsible for managing the order. This ensures that communication can be directed appropriately.
4. Provide your 'City', followed by the 'Telephone Number' and 'Email Address'. Ensure these are accurate for any follow-up communication.
5. Include the 'Fax Number' for documentation purposes, along with the 'Patient Reference' which may be an identifier related to the patient's care.
6. Enter the 'Purchase Order Number', which may be required for tracking and confirmation of the order.
7. Specify the 'Planned Treatment Date' and 'Planned Treatment Time'. These indicate when the treatment is scheduled to occur.
8. Indicate the 'Standard Dose Required' by filling in the two dose fields (Standard Dose #1 and Standard Dose #2) in gigabecquerels (GBq) along with the quantities and calibration dates.
9. If a 'Custom Dose Size' is needed, complete the corresponding fields for Custom Dose #1 and Custom Dose #2, ensuring you include calibration dates, if applicable.
10. Confirm that the order meets the necessary deadlines, especially for Custom Dose Size orders which must be submitted by the Tuesday before the Sunday calibration date.
11. Indicate any required 'Administration Sets' by entering the quantity needed.
12. Once all fields are filled out, review your entries for accuracy before selecting the option to 'Submit Form'.

Start completing your TheraSphere Order Form online today for prompt processing.