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General Physician Simulation Orders (60 min) Use Match and 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.) Use Match and Adjust Anatomy for Portal Imaging to establish isocenter daily for the entire course of treatment. Pre-sim Do not page attending prior to immobilization or Patient Set-Up: (check all that apply) Position: Supine Immobilization: Arms: Legs: Head: Prone Thorax board Blue Pad Up On abdomen Kneefix Headrest Breast board Cradle At side On chest Toes banded Pillow 3 pt mask 5 pt mask Akimbo Scheduling/Authorization Approval Simulations will not be scheduled unless filled out Stage: ECOG status: Choose Treatment method: 3DCRT Total Gy: Scheduling Needs (optional): # Fractions: Concurrent Chemo: No TX5/6 Eligible: Choose Volumes Date: 3 business days Location of targets: Additional immobilization & simulation instructions: (e.g. placement of markers, wires, bite block, pacemaker etc…) Scan Parameters: Upper border: Lower border: Slice thickness 3mm or CT reference point: middle of site or Field Parameters: (check all that apply & fill in appropriate information) Field arrangement: AP/PA AP PA Opposed Laterals Energy: 6X 16X Isocenter: MPD 100 SSD (prescribed to desired depth) Field borders: Superior @ , Inferior @ , Lateral borders @ Structures to be contoured by sim therapist: None or Blocking: None or Page attending Resident to check scan Simulation Directive Completed By: <Entered By> Simulation Ordered by: <Signed By> <Current Date> <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 Copyright * 2008 The Regents of The University of Michigan Obliques CT Patient Activity Document Interpreter (Language) Special Scheduling Instructions Pre-Simulation Screening Schedule: When Provider is in Clinic Consent or Reconsent Completed: _ Protocol consent submitted to Data Manager: _ Blood Draw order entered into Mi-Chart Schedule Lupron Injection Date Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430) Child Life Specialist Pacemaker or AICD Patient (if so call 5-3968 for urgent consult) Pediatric patient (18 and under), Adult Page 30435 with patient name, registration number and appointment information 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 : 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