SeeDOS Pre Plan Form (example only)

The following form should only be used after registration with SeeDOS Ltd.

Please hard copy the form and send completed form with your pre-plan ultrasound scans to the address shown below.

INSTITUTE OF MEDICAL PHYSICS AND ENGINEERING

Contact :Mr A Flynn, Cookridge Hospital, Hospital Lane, LEEDS LS16 6QB, West Yorkshire

Tel +44 (0) 392 4312 Fax +44 (0) 392 4122 Email af@medphysics.leeds.ac.uk

Please complete this form to ensure that you have supplied Cookridge hospital with all the information required to carry out your dose planning.

ONE COMPLETED COPY OF THIS FORM MUST ACCOMPANY EACH SET OF ULTRASOUND SCANS

                    Consultant Urologist:

Tel No:

Email address:

Fax No:

Consultant Radiologist :

Tel No: 

Email address:

Fax No:

Consultant Oncologist :

Tel No:

Email address:

Fax No:

             Medical Physicist :

                    Tel No: 

                  Email address:

                    Fax No:

Patient name :                                                             Patient identification number :

Date of scan :                                                             Number of ultrasound slices taken :

Number of ultrasound slices to be used for planning :

First slice number to be used for planning :

Final slice number to be used for planning :

Magnification of ultrasound slices (must be less than 1.98) :

(The magnification must be the same in the X & Y directions)

Activity of the seeds to be used for plan: mCi

Prescription dose required (160Gy assumed if left blank):

Date volume study sent to Cookridge Hospital :

Date plan required for implant :

If you are interested in any of the products or services mentioned here, please fill out a Quotation Request Form  or an Enquiry Form so that we may promptly respond to your detailed request.