Cumulative Patient Effective Dose Request Form

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Please fill out the form below to have a West Physics representative contact you to arrange for a service or product quote for your facility.

Full name*
Title*
Email*
Phone
Company or Facility Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Brief Description of Service or Product Needs*
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Our address and telephone numbers are:

West Physics
3825 Paces Walk SE
Suite 250
Atlanta, GA 30339

770-435-9186 • 1-866-275-9378 • FAX 770-599-2333

Office Hours: West Physics maintains liberal office hours for the convenience of our customers nationwide.

Monday-Friday:

9AM – 8PM Eastern Time
8AM – 7PM Central Time
7AM – 6PM Mountain Time
6AM – 5PM Pacific Time

Closed Weekends & U.S. National Holidays

All Modalities:

DICOM images should be uploaded to the secure server or CD’s mailed to West Physics Remote Services at 3825 Paces Walk SE, Suite 250 Atlanta, GA 30339. Most information needed for the calculation will be contained in the images. Please also provide the following:

If available, please provide: Dose Report listing exam clinical settings (i.e. kVp, mAs, time, etc.) and Most recent Annual Physics Report if not surveyed by a WP Physicist

General Information:

Facility Name:

Date of Study:

Contact Person and Title for Report:

Equipment make, model and serial #:

Modality Specific Information:

Fluoroscopy and Radiography:

Protocol/Procedure Types:

Number of Each Procedure Type:

Nuclear Medicine/PET:

Procedure/Exam Types (i.e. bone SPECT):

Number of Each Procedure Type:

Radiopharm(s) (i.e. FDG, Tc-99m(MAA)):

Activities (mCi):

Computed Tomography:

Protocols Used:

Number of Each Procedure Type:

CTDIvol(s) (mGy):

DLP(s) (mGy*cm):

Comment:

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