Department:
Radiotherapy / Medical Physics
Replacing:
RT.BK-04(v4)
QART document level:
Level 4 Forms, Datasheets, Local rules
RADIOTHERAPY MANAGEMENT FORM
Patient information
Name:
Please
where applicable
Interpreter/Language
Diagnosis:
L number:
DOB:
Treatment site:
Gender: M
F
Walk
Chair
OP
IP
New
patient
Stretcher
Ward
Y
N
Y
N
Concurrent chemo: Y
Regime:
N
Consented for RT
Contact #:
Previous RT:
Details:
Email :
Address:
Y
N
Pacemaker / ICD: Y
N
Clinical trial
Scheduling / Funding
CT and Positioning (standard scanning levels unless on relevant diagram)
Consultant attending CT
Preferred CT date / time:
Positioning:
Supine
Arms: up
Preferred RT Start date / time:
Contrast
Prone
on chest
Head extended
Self-pay
Embassy Name:
Insurance Co and Policy no:
Others
by side
flexed
IV
Oral
Gastrografin
as per protocol
Omnipaque 300
as per protocol
Immobilisation:
Shell
Mouth bite
If known kidney disease
Visipaque 270
as per protocol
Others:
(Risk will be assessed by radiographer /
clinical assistant)
Rad-led palliative localisation*
(*MUST be completed & consultant to
review within 1st 3 #
or
Treatment planning / Rad-led breast mark-up
Motion management:
Treat at free breathing
Treat at breath hold
Breast / Chestwall
DIBH
Abdomen / Chest
IBH
EEBH
ITV
by date specified:
)
Not required:
Reason(s)
Volume date/time
__________
*Please inform planning if you are away during treatment period & nominate/arrange
Clinical Oncologist cover
__________
Intended planning technique:
VMAT / IMRT
3D Plan
Intended prescription/planning details:
Ph1 /
Site 1
Photon 6
Electron 6
9
VSim
Cyberknife
Site 2
Ph2 /
Gy/#
Gy/#
Depth in cm/MPD
Depth in cm/MPD
12
Fiducials needed?
16
16
20
MV
MeV
Fusion needed?
Photon 6
Electron 6
Bolus
9
16
16
12
(
20
cm
MV
MeV
#)
Additional diagnostic imaging required :
Modality
Date
Pre-op / post-op
Location
CONSULTANT SIGNATURE (REFERRER/PRACTITIONER)
PRINT
DATE
Please return to Booking office Tel 020 7616 7759 Fax 020 7616 7792 Email radiotherapybookings@thelondonclinic.co.uk