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Lung Set Fields Sim Directive (60 min) Iso Verification: Choose Match &Adjust Anatomy with Portal Imaging to establish isocenter on days 1 and 2. If isocenter is within tolerance limits continue to use Match and Adjust Anatomy every 5th fraction to verify patient setup. (If tolerance is out of limits follow portal imaging policy.) Match &Adjust Anatomy with Portal Imaging to establish isocenter daily for the entire course of treatment. Page prior to immobilization: Attending Resident Physics Scheduling/Authorization Approval Simulations will not be scheduled unless filled out Stage: ECOG status: Choose Treatment method: 3DCRT Total Gy: Patient immobilization: Supine or Thorax Board or Arms up or Head rest or Knee Fix Other Scheduling Needs (optional): # Fractions: Choose TX5/TX6 eligible (6x only): Choose Concurrent Chemo: Choose MROQC Scan Parameters: Free breathing or Upper Border @ C1/2 interspace or Lower Border @ L1/2 interspace or Slice thickness 3mm Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below) Oral contrast, 3 oz Scan-C immediately prior to first scan with contrast If patient answers yes to any of these questions below – order a steroid prep 1) Do you have a CT IV contrast (x-ray dye) allergy? Choose 2) Do you require a steroid prep? Choose If patient answers yes to the question below and has not had Creatinine drawn within 6 months - order and send patient for lab draw Have you had the following medical conditions or procedures? a) Renal Transplant? Choose b) Kidney disease or failure? Choose Additional Simulation Instructions: (e.g., placement of markers, wires, etc.) Field Parameters: Field arrangement: opposed AP and PA fields or Energy 6X or Isocenter @ MPD or Field borders: Upper border @ Lower border @ Lateral borders @ Structures to be contoured by sim therapists: No Blocking or Custom blocking by MD Page attending Page Resident to set & check set fields Simulation Directive Completed By: <Entered By> <Current Date> Copyright * 2008 The Regents of The University of Michigan Simulation Ordered by: <Signed By> <Signed date time> Electronically signed by controlled access password Simulation Note: I was present to Choose Generate Isodose Plan Attending Signature: <Approved By> <Approved date time> Electronically signed by controlled access password CT Patient Activity Document Interpreter (Language) Pre-Simulation Screening Schedule: When Provider is in Clinic Consent or Reconsent Completed: _ Protocol consent submitted to Data Manager: _ Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430) Pacemaker or AICD Patient (if so call 5-3968 for urgent consult) Woman age 11-55 (pregnancy screening form ) _ Medical Assistant has completed test _ Prior RT at outside institution and records (including treatment Plan) needed _ If yes, please provide location/physician name and approximate dates of treatment and notify Record Room @ 64286 : Special Scheduling Instructions Blood Draw order entered into Mi-Chart Schedule Lupron Injection Date Child Life Specialist Pediatric patient (18 and under), Adult Page 30435 with patient name, registration number and appointment information Radiation Oncology Protocol Coordinator Rad Onc Protocol No. Check Rad Onc Protocol Coordination below: April Proudlock 936-9521 (Pager 35596) Mary Akagi 936-3187 (Pager 34329) Michelle Castle 615-8492 (Pager 34592) Kevin Doyle 232-3841 (Pager 34665) Copyright * 2008 The Regents of The University of Michigan