Sirtex - China Order Form

公司帐号

Account Number *

如果您不知道帐号，请发送电子邮件至 csapac@sirtex.com
(if you don't know your account number, email csapac@sirtex.com)

Telephone * 请注明国家代码
Please state country code

Additional Confirmation Recipient(s) 请用逗号和空格分隔每个电子邮件地址
Please separate each email address with a comma and a space

配送信息
Delivery Information

机场目的地

Airport Destination *

Telephone* 请注明国家代码
Please state country code

治疗医院信息
Treatment Site Information

Treatment Site Name*

治疗医院账号

Account Number*

如果您不知道帐号，请发送电子邮件至 csapac@sirtex.com
(if you don't know your account number, email csapac@sirtex.com)

治疗医院地址

Treatment Site Address*

负责人

Contact Person*

账单地址信息
Billing Address Information

帐单地址

Billing Address*

Purchase Order Number*

订购单

Purchase Order

Activity at calibration day/date is 3Gbq (± 10%) at AEST 09:00:00hrs.

Warning! The selected delivery date is prior to the first available delivery date: . Please call Customer Service.

案例编号 1
Case Number 1

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 1

治疗医生姓名

Treating Physician Name*

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

案例编号 2
Case Number 2

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 2

治疗医生姓名

Treating Physician Name *

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

案例编号 3
Case Number 3

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 3

治疗医生姓名

Treating Physician Name *

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

案例编号 4
Case Number 4

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 4

治疗医生姓名

Treating Physician Name *

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

案例编号 5
Case Number 5

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 5

治疗医生姓名

Treating Physician Name *

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

案例编号 6
Case Number 6

订单类型
Order Type *

Quantity	Item Number	Item
	SIR-Y001	钇[90Y]树脂微球 SIR-Spheres Y-90 resin microspheres
	SIR-K002-CHNSIR-K002	输送装置包含 1个·输送套件 1个V-瓶和1个V-瓶架 Accessories Pack (includes: one (1) Delivery Set, one (1) V-Vial and one (1) V-Vial Holder)
	SIR-V001 BOXED	输送套件 V-Vial
	SIR-D001 BOXED	输送套件 Delivery Set
	SIR-S001	注射器防护罩 Syringe Shield
	SIR-B001 BOXED	输送盒 Delivery Box
	-	其他，请注明 Other, please specify:

Treating Physician Information - Case 6

治疗医生姓名

Treating Physician Name *

治疗医生专科
Treating Physician Specialty

肿瘤类型
Tumour Type*

转诊医师

Referring Physician

治疗日期

Treatment Date *

测绘日期

MAA Date

监考员案例
Proctor Case*

Yes No

患者身份识别

Patient ID*

监考人员姓名

Proctor Name*

患者身份识别

Patient ID

笔记 Notes

提交此订购表即表示接受并同意遵守社泰订购和取消政策。客户确认在订购之前已执行所有必需的步骤（即保险审批、实验室工作等）。提交订购表将表明所有各方均已获得适当的许可证来处理该产品。
Submission of this order form constitutes acceptance and consent to adhere to the Sirtex Order and Cancellation Policy. Customer acknowledges that all required steps have been performed prior to ordering (i.e. insurance approval, lab work, etc.). Submission also constitutes that all parties have appropriate licensing in place to handle our product.

Product Ordering

China Order Form

钇[90Y]树脂微球中国订购表
SIR-Spheres^® Y-90 resin microspheres Order Form - China

配送信息
Delivery Information

治疗医院信息
Treatment Site Information

账单地址信息
Billing Address Information

Treating Physician Information - Case 1

Treating Physician Information - Case 2

Treating Physician Information - Case 3

Treating Physician Information - Case 4

Treating Physician Information - Case 5

Treating Physician Information - Case 6

笔记 Notes

Product Ordering

China Order Form

钇[90Y]树脂微球中国订购表SIR-Spheres® Y-90 resin microspheres Order Form - China

配送信息 Delivery Information

治疗医院信息 Treatment Site Information

账单地址信息 Billing Address Information

Treating Physician Information - Case 1

Treating Physician Information - Case 2

Treating Physician Information - Case 3

Treating Physician Information - Case 4

Treating Physician Information - Case 5

Treating Physician Information - Case 6

笔记 Notes

钇[90Y]树脂微球中国订购表
SIR-Spheres^® Y-90 resin microspheres Order Form - China

配送信息
Delivery Information

治疗医院信息
Treatment Site Information

账单地址信息
Billing Address Information