ONLINE DOSE REPORT FORM TO BE PRINTED ON YOUR LETTER HEAD

INSTITUTION NO :_____________

NAME OF THE PROPRIETOR/

HEAD OF DEPARTMENT :__________________________________________________________________

NAME OF YOUR INSITUTITON :__________________________________________________________________

CONTACT NO. :__________________________________________________________________

EMAIL ID TO BE REGISTERED
WITH RENENTECH :__________________________________________________________________

LIST OF RADIATION EQUIPMENTS

IN YOUR ESTABLISHMENT :__________________________________________________________________
___________________________________________________________________
___________________________________________________________________

TERMS AND CONDITIONS :

1. Renentech Laboratories Pvt Ltd will not be held responsible if your registered email ID’s and password
would be shared with any unauthorized person.

2. Only those emails ID’s which are informed to us on your letterheads will be registered on our website
www.renentech.com to enable you to download the dose reports.

3. We at Renentech Laboratories Pvt Ltd hereby take your permission to upload your periodic dose report
on our website which will be accessible to you under your registered email ID’s.

4. Dose report will be accessible only after receiving of 60% of TLD cards from your institution of the
particular service period including control card.

I the undersigned agrees all the above terms and conditions and allow you to upload our dose report on your
website.

Sincerely

Signature with seal

Proprietor/Head of Department