Phantom Library Equipment loan request

Consent for storing submitted data *

Yes, I give permission to store and process my data

Contact details

IPEM Member full name *

IPEM Membership number *

Hospital department *

Hospital/Trust name *

Equipment must be delivered to the IPEM Member's work address. Please ensure full delivery address is given.

Hospital address *

Hospital post code *

Departmental reception phone number for courier *

IPEM Member's email address *

Work telephone number *

Mobile number

Further delivery details

Equipment details

Item required on loan *

Contrast Enhanced Spectral Mammography Phantom (CESM)

Brachytherapy Applicator Dosimetry (BRAD) Phantom (Please note this item is not currently available)

Date equipment required *

Date of return *

It is the responsibility of the IPEM member to return the equipment to IPEM by suitable carrier. Items must be returned within one day of the event. (Carrier expenses will be reimbursed on submission of an expenses claim).

Location item will be kept at if different from work address above (please note that the item should be kept at your work address and not a private address)

Other relevant information

Please state

Terms & Conditions

I agree that I have read and understood the Terms and Conditions above and agree to abide by these for the loan of the above equipment. *

I agree that I have read and understood the Terms and Conditions above and agree to abide by these for the loan of the above equipment.

1. Equipment on loan is for exclusive use under the supervision of the above named IPEM Member and may not be transferred to any other party without the express permission of IPEM. 2. IPEM cannot guarantee the accuracy of the equipment and the Member must satisfy themselves as to its suitability for their intended use. 3. The equipment on loan must not be modified in any way except as would be reasonably expected for its intended use. 4. Reasonable precaution will be taken by IPEM to ensure that the equipment is safe to use and any defects must be reported to IPEM immediately. 5. The equipment is owned by IPEM and insured by us, however the member is responsible for the safe-keeping of the equipment. 6. It is the Member’s responsibility to ensure the safe return of the equipment to IPEM (or other location by agreement) in its original state and packaging on the date specified above. 7. The equipment is provided for demonstration and instructional purposes only and must not be used in connection with actual clinical treatment. The equipment must be used in conjunction with the manufacturer’s guidelines and instructions. 8. For the avoidance of doubt, IPEM can accept no responsibility for liability arising out of the use (proper or improper) of the equipment while in the possession of the member.

How do we use your data?

All information collected is treated in strict compliance with the Data Protection Act. You can read our Privacy Policy here.