Products of InterestPlease select which products you are interested in ordering:* FlexiBol / Uniform Thickness Bolus Electron Cutouts Electron Bolus (BolusECT) Proton Apertures and Range Compensators decimal3D Other (please describe in the Survey Wrap Up "Notes" section) Tell Us About Your SiteType* Hospital Free-standing Number of Treatment Machines*1234 or moreDon't know / Prefer not to answerHow many external beam treatment machines, e.g., linacs, does your site have?Average Patient Volume*0 to 10 / week11 to 20 /week21 to 40 / week41 to 60/ weekMore than 60/ weekDon't know / Prefer not to answerPlease select from the list.Electron Patient Volume*Less than 10% of total patient volume11% - 20% of total patient volumeMore than 20% of total patient volumeDon't Know/Prefer Not To AnswerPlease select from the list.Treatment Types* Breast/Chestwall External Brachytherapy Skin Cancer with External Beam Total Body Irradiation (TBI) I Prefer Not To Answer Technologies* VMAT SBRT Surface Guidance (SGRT) I Prefer Not To Answer Institution Name / Billing InformationParent Company Name:* Institution / Clinic Name:* Address 1:* Address 2: City:* State:* Zip:* Clinical and Administrative ContactsThe Primary Clinical Contact is the principal lead for coordinating .decimal software installation, facilitating online training schedules, and working with our representatives to ensure proper and timely implementation Primary Clinical Contacts agree to make themselves reasonably available to .decimal representatives during this process.Primary Clinical Contact:* Primary Contact's Title:* Phone (Primary Contact):* Email (Primary Contact):* Administrative Contact: Phone (Administrator): Email (Administrator): Shipping InformationNote: You may enter "same" for fields that are the same as previously entered for Institution / Billing Info.Parent Company Name:* Institution/Clinic Name:* Address 1:* Address 2: City:* State:* Zip:* Accounts PayableAccounts Payable Contact:* Phone (Accounts Payable):* Email (Accounts Payable):* Fax (Accounts Payable): After Hours / Emergency Contact:* Phone (After Hours): Email (After Hours): Information Technology / Information SecurityIT or IS Contact:* Email (IT or IS Contact):* Do you have the approval to install .decimal software?* Yes Not yet (pending IT review) Unsure Software UsersFor HIPAA purposes, individual software logins are required. Please provide the following information for all personnel who require access to decimal applications (e.g., "p.d" software).Name 1 | Title 1 | Email 1 | Phone 1* Name 2 | Title 2 | Email 2 | Phone 2 Name 3 | Title 3 | Email 3 | Phone 3 Name 4 | Title 4 | Email 4 | Phone 4 Name 5 | Title 5 | Email 5 | Phone 5 Name 6 | Title 6 | Email 6 | Phone 6 Name 7 | Title 7 | Email 7 | Phone 7 Name 8 | Title 8 | Email 8 | Phone 8 Additional Contacts for Order ConfirmationsThese contacts will receive order confirmation notices.Contact: Email: Contact: Email: TPS and Linac InformationIf you have more than two applicable TPS systems or three applicable linacs, you can enter the additional information in the notes section at the end.Primary TPS: Vendor, Model, and Version (e.g., Varian Eclipse 15.2)* Secondary TPS: Vendor(s), Model(s), and Version(s) Primary Linac Machine Name:* Primary Linac Manufacturer, Model, and Source-to-Tray Distance (cm) if different than 95 cm:* 2nd Linac Machine Name: 2nd Linac Manufacturer, Model, and Source-to-Tray Distance (cm) if different than 95 cm: 3rd Linac Machine Name: 3rd Linac Manufacturer, Model, and Source-to-Tray Distance (cm) if different than 95 cm: Note 1. Machine name has to match the TPS name.Note 2. If you have multiple machines, please contact .decimal for proper set up.Required for Bolus ECTIn order for us to properly setup your account, we must obtain the energy and its respective R90 depths for your machines.Energy (MeV): R90 Depth (20x20 or greater): decimal3D Setup ParametersIf you are a decimal3D customer, please visit the following link to enter required parameters to ensure proper setup of your hand-held 3D scanner.Please go to this form to enter parameters required to complete your decimal3D configuration.Survey Wrap UpAny additional things you like to share, use this section.How did you hear about us?*ReferralGoogle SearchEblastVideoNotes:NameThis field is for validation purposes and should be left unchanged.
