Fetal Dose Calculation 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-WEST (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 [email protected]. 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 #:

Exam ID or MRN (optional):

Gestational Age (weeks):

Conceptus Depth (cm):

Patient AP Caliper (cm):

Patient’s Ht (cm) and Wt (kg):

Modality Specific Information:

Fluoroscopy and Radiography:

Average kVP:

Average mA or mAs:

Source to Patient Distance (cm):

Source to Detector Distance (cm):

Configuration (Chest, Table, etc.):

Exposure Duration (sec):

Exposure Direction (AP, PA, Lateral):

# of Exposures (RAD only):

Field of view size (cm):

Fluoro Time (min):

Computed Tomography:

Protocol Used:

Scan Mode (Axial or Helical):

Average kVp:

Average mAs:

Pitch:

Phantom Size:

CTDIvol (mGy):

DLP (mGy*cm):

Nuclear Medicine/PET:

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

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

Activity (mCi):

Files, if applicable

Drop files here or

Max. file size: 50 MB.

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