Transnational Access Form – Clinical access

    Fill in the following form to request beam time for clinical research

    Applicant's data

    Patient data

    Report of the applicant physician

    1. Patient information: disease diagnosis, disease stage, non-cancer history, detailed cancer history, ongoing therapies, drugs, active problems and any other information useful for the evaluation
    2. Information on the reasons and objectives of the request to use the facility
    3. File upload of (each in backward chronological order, clearly dated files):
    • physician’s letters, including tumor board (if available) and operation reports (if surgery was performed)
    • histology
    • imaging results (MRT, CT, PET-CT)
    • prior irradiation plans