Radiation Exposure History Request

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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 from another institution for a newly hired employee

General Information:

Current Employer Facility Name:

Current Employer Contact Person and Title for Report:

Current Employer Contact Person Email:

Current Employer Department:

Current Employer Employment Date:

Current Employer RSO name:

Current Employer RSO email:

Current Employer RSO phone number:

Comment:

Please download the attached request form, have the employee fill it out and sign it, then upload the signed statement from the individual authorizing release of their dosimetry record with this request. If you do not attach the form, we will contact you to assist with obtaining a signed release from the individual.

Click the link below to download the form:

Download Form

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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