SETUP - SHEET

Managed by Narayana Health

Kakryal, Katra, Reasi, J&K. Ph. : 01991-285511, 01991-285522

Name : _______________________________________ Diagnosis : _____________________________________

Site of RT : ____________________________________ RT Number :____________________________________

Scan Date :
Patient Position :
Arms
Neck
Orfit
Neck Rest
Vacloc
Imaging
Slice thickness-mm
Contrast
Creatine Level
Shoulder Traction
Copper Wire

T.I. ___________
Supine/Prone/_Lateral/SitStand
By-side/Above head/Over chest
Full extension/Neutral/Flexion/
Turned to___side
Head/Head-neck/Abd-Pelvic
A/B/C/D/E/Prone
Nil/Partial/Overall
CT/PET-CT/ MR
1/2/3/5/8
Yes/No
Yes/No
Yes/No

Sign RTT1 :

A/B/C

Sign RTT2 :

Knee Rest
Wing Board
Breast Board
Bolus :
Bowel
Oral Contrast
Fasting
Urination
Bladder Protocol

Time Protocol

Contrast Allergy

Yes/No

Serology

Nil/HIV/HBV/HCV

Sign Nurse :

Setup Date and comments :

Anesthesia Instructions :
Sign Physician (at Setup):

Yes/No
Yes/No No:
(1-24)
Yes/No
A[ ] T [ ] H[ ]
Site :
mm:
Passed/No
Yes/No
Yes/No
Passed/No

Sign Physicist (at Setup) :

Plan of verification : EPID/CBCT

Acceptable thresholds range (mm) for no shifts/shifts :
Thresholds range (mm) for calling physicist/Physician :
Replaning CT At____#Date :___________ Cast : Same/remould/recast, Reason :
Replaning CT At____# Date :___________Cast : Same/remould/recast, Reason :

PRESCRIPTION FOR
CT SCAN CONTRAST

Managed by Narayana Health

Kakryal, Katra, Reasi, J&K. Ph. : 01991-285511, 01991-285522

DEPT. OF RADIATION ONCOLOGY

Name :________________________________________________________ Age :________ Gender :___________

Hospital No. :_______________________________ Date : ______________________

1.

Inj. Omnipaque (50ml)

2.

Normal saline (100ml)

3.

10cm extention

4.

20cc syringes

5.

5cc syringe

6.

18G Needle

7.

20G Venflon

8.

Alcohol swabs

9.

Clean ups

10.

50ml syringe

PAYMENT RECORD
RADIATION ONCOLOGY

Managed by Narayana Health

Kakryal, Katra, Reasi, J&K. Ph. : 01991-285511, 01991-285522

Patient Name______________________________________________________Hospital No.:____________________

Scheme : SMVD/ Pvt. Insur / International_______________________________________

Technique : CONV /PALLIATIVE RT/ 3DCRT / IMRT / IGRT / GRT / VMAT / SRT / SRS /TBI_______________________
Provisional RT Charges Breakup
CODE

PROCEDURE

FRACTIONS

AMOUNT

TOTAL
Date :
BILLING COMMENTS (CORPORATE):
Billing Secretary:

DATE

Doctor sign :

BILL NUMBER

AMOUNT

TOTAL

BILLING CLOSURE COMMENTS :

Secretary :

Managed by Narayana Health

Kakryal, Katra, Reasi, J&K. Ph. : 01991-285511, 01991-285522

CONSENT FOR RADIATION

THERAPY

FOR PATIENT: Read the information

As a patient, you have the right to be informed about your condition and the recommended radiation therapy procedure
to be used to treat your condition. This disclosure is not meant to alarm you, is intended to inform you of those risks so
that you may give or withhold your consent to the recommended procedure on an informed basis. Please carefully
review the following and if you choose to proceed with this treatment, sign this consent in the space below:
I (we) hereby voluntarily request and authorize Dr. ______________________________________________as my
physician, and such associates. Technologists and the health care providers at SMVD Narayana Super Speciality
Hospital as they may deem necessary to treat my condition which has been explained to me (us) as:
_____________________________________________________________________
I (we) understand that the radiation therapy procedure(s) are planned for me and I (we) consent to and authorize these
procedure(s) (specify technique and site):
I (we) understand that there may be side-effects or complications from radiation therapy, either during or shortly after
the course of treatment ("early reactions"), or some time later ("late reactions"), These reactions affect only the areas
actually receiving radiation therapy as:
______________________________________________________________________________________________
In case of minors
Signature of Guardians
______________________________________________________________________________________________

ALL FEMALES MUST COMPLETE: I (we) understand that radiation can be harmful to the unborn child.
[ ] I am, [ ] I could be, [ ] I am not pregnant, [ ] Not applicable
I (we) further authorize the taking of photographs or placing of tattoo or skin marks necessary for treatment. This
procedure requires making of mask and planning CT scan with/without contrast and some patient may show allergy to
contrast which I (we) understand is important for the procedure. The nature and purpose of the proposed procedure,
the alternative methods of treatment, and the risks and hazards if treatment is withheld have been explained to me (us)
by my physician. i (we) have had an opportunity to discuss these matters with my physician and to ask questions about
my condition, alternative methods of treatment and the proposed procedure(s). I (we) understood the discussion in
________________language by___________________________(interpreter).
i {we) also understand that this treatment may have some interruption due to machine related or other issue which the
treating team is not deemed liable. I (we) also understand that no warranty or guarantee has been made tome (us) as
to result or cure.

PATIENT

OTHER LEGALLY RESPONSIBLE PERSON

Signature
Name

Signature
Name

Date & Place :

PHYSICIAN

INTERPRETER:

Signature
Name

Signature
Name

Managed by Narayana Health

Kakryal, Katra, Reasi, J&K. Ph. : 01991-285511, 01991-285522

CLINICAL RECORD

NAME:_____________________________________________________AGE :__________GENDER:__________
HOSPITAL MRN :____________________________________RT No.:_______________DATE :________________
MOB :______________________________________E-MAIL:___________________________________________
DIAGNOSIS:__________________________________________________________________________________
CONSULTANT : _______________________________________________SURGERY DATE :_________________

TECHNIQUE : CONV/ PALLIATIVE RT /3DCRT / IMRT / IGRT /

VMAT / SRS / SRT / SBRT / TBI / TSET
Radical / Adjuvant / Palliative / Prophylactic
CO-MORBIDITIES : DM / HT / CAD / Hypothyroid / CORD / TB Renal
BASELINE MEDICATIONS :
CONCURRENT CHEMO PLAN:
DIET PLAN : Oral / RT / PEG / Jejunostomy
COMMENTS :
IMAGE FUSION : CT / MRI / PET, Pre / Postop, Date
DISCUSSION WITH SURGEON / RADIOLOGIST :
PREVIOUS RT DETAILS :

PH 1.

PH : 1/2 / 3 / 4. SEQ / SIB, LA1/2

DOSE PRESCRIPTION :
PH 2.

TARGET DELINEATION:
PH 3.

PTV MARGINS :
OAR CONSTRAINTS :
PRESCRIPTION CHANGE:
VERIFICATION PLAN : CBCT / EPID

Signature : Radiation Oncologist