Online Order Form

Returning customers

Order through TheraSphere Now - a free cloud-based platform that provides real-time inventory viewing, dose and accessory ordering, delivery tracking, and more!

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If you do not wish to use TheraSphere Now, please proceed to the order form below.

*Required

Region

Site name

City

Location ID

Contact name

Email address

Fax number

Telephone number

Treatment reference number

Please do not include patient identifying information (e.g. patient name or date of birth)

Purchase order number

Planned treatment date (mm/dd/yyyy)

Planned treatment time (hh/mm AM/PM)

Treating physician name

Please type the name of the physician that will be treating the patient.

Patient treatment can be planned for 12 days following Calibration Date.

Dose #1 (GBq)*

Dose #1 quantity*

Dose #1 calibration date (mm/dd/yyyy)

Dose #2 (GBq)

Dose #2 quantity

Dose #2 calibration date (mm/dd/yyyy)

Dose #3 (GBq)

Dose #3 quantity

Dose #3 calibration date (mm/dd/yyyy)

Dose #4 (GBq)

Dose #4 quantity

Dose #4 calibration date (mm/dd/yyyy)

Dose #5 (GBq)

Dose #5 quantity

Dose #5 calibration date (mm/dd/yyyy)

Please enter the number of administration sets

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TheraSphere is a registered trademark of Theragenics Corporation used under license by Boston Scientific Medical Device Limited, a wholly owned indirect subsidiary of Boston Scientific Corporation.

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Online Order Form

Returning customers