Dose History Request - West Physics

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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

To request radiation history for a current or former employee (generally to answer a request from another facility or former employee’s new employer)

General Information:

Facility Name:

Contact Person and Title for Report:

Department:

Employment Dates

Exposure Dates

Dosimetry Vendor (i.e., Landauer or Mirion):

Dosimetry Vendor Account number:

Dosimetry Vendor Sub-Account:

Participant ID:

Comment:

File

Drop files here or

Max. file size: 50 MB.

*Please upload a signed statement from the individual authorizing release of their dosimetry record. If your facility does not have such a form, submit the request and we will contact you to assist with obtaining a signed release from the individual.

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