TÜV Rheinland Philippines, Inc.
FOR OSLD TEA M USE :
Ground Floor La Fuerza Building 1, 2241 Don Chino Roces Ave. 1231 Makati City, Philippines Tel. No.: 812-8887 (option 2) E-mail Address:
[email protected] [email protected]
Reference No: Filing Date:
FOR NEW APPLICATION APPLICATI ON
1. CLIENT INFORMATION a. Complete Facility Name:
STA. CRUZ MEDICAL AND DIAGNOSTIC DIAGNOSTIC CENTER
b. Type of Office
☒Main ☐ Branch
c. Facility Address 1:
# 287 Poblacion South
d. e. f. g. h.
Facility Address 2: Contact Person: Billing Address: Bill-To Person: Tel No.: Fax No.:
☐Others:
FOR RENEWAL OF SERVICE
Specify Type
Sta. Cruz, Zambales Anabelle P. Manalo #287 Poblacion South, Sta. Cruz Zambales Anabelle P. Manalo 047 831 2848 047 831 2848
Zip Code Designation:
2213 Radiologic Technologist
Designation: Mobile No. E-mail:
Radiologic Technologist 09562596181
[email protected]
2. RADIATION EMITTING EQUIPMENT (Use additional sheets if necessary) Brand
a. X-ray b. CT-Scan c. Mammography d. Other: (Specify)
Model
GE
GE
Details (kV and mA) 110 kVp, 500 mAs
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3. RADIATION DETECTORS AND PERSONAL PROTECTIVE EQUIPMENT a.
Radiation Detector
☐ Survey Meter
☐ Pen Dosimeter
b.
Protective Protective Equipment
☒ Lead Gown
☐ Lead Goggles
4. USER/S INFORMATION Name (Last Name, First Name, Middle Initial) 01
Anabelle P. Manalo
F
02
Dr. Isidoro N. Ayson Jr.
03
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04 05 06 07 08 09 10 11 12 13 14 15
Gender
M Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender Gender
5. NUMBER OF BACKGROUND CONTROL BADGES
Others: Click here to enter text. ☐ Thyroid Shield
Designation Chief Radiologic Technologist Radiation Protection Officer
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Department Name
Pregnant (Y/N)
Radiology Department
N
Radiology Department
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N N N N N N N N N N N N N N
SPECIFY LOCATION
1 Staff Room 02 Click here to enter text. Staff Room 03 Click here to enter text. Staff Room NOTE: Should you have more than 15 users or more than 3 background control badges, kindly place details in an attached sheet. 01
6. SUBSCRIPTION SUBSCRIPTION PLAN Monthly Monitoring *Receives 12 dose reports in a year
7. TYPE OF DELIVERY 8. BADGE SUMMARY
☒ LBC
Total No. of Users:
Bi-Monthly Monitoring *Receives 6 dose reports in a year ☐N/A (For Pick-Up)
2
Total No. of Background Badges:
1
NOTE: Prices are VAT inclusive. Prices include free assessment of dose badges, delivery of dose reports. Prices are subject to change without prior notice.
9. AGREEMENT. ☒ By ticking this box, it is understood that all information provided in this application is true, correct and complete. I accept the terms and conditions of subscription to OSLD Dosimetry Services provided by TÜV Rheinland Philippines, Inc., including any amendments thereto.
Anabelle P. Manalo Full Name of Representative
11/7/2018
Date Signed
Kindly send this completed form to
[email protected] or directly submit it to our office. Upon our acknowledgement, acknowledgement, a quote will be sent to you with the corresponding breakdown of fees. You will receive your badges through your preferred preferred delivery type 15 working days after we have received a copy of your full payment receipt. For questions or clarifications, please feel free to contact contact us at 812-8887 (option 2).
AFP:Dosimetry2014rev19
