Change in Badge Service Form

Change in Badge Service Form
Please use this form if you need to add a badge, deactivate a badge, or add a fetal badge.

If you are looking to reassign a badge, please fill out the Badge Reassignment Form.
Clinic Practice Name*
Penn Vet Account # (If Known)
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Phone Number*

Area CodePhone Number
RDC Group # (If Known)
Add Badge - New EmployeeAdd Badge - OtherDeactivate Badge - Unaffiliated EmployeeAdd Fetal Badge - Pregnant Employee

Add Badge - New Employee
New Employee's Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
MaleFemale
Rush Processing ($50 Fee) Badge received in 1-2 business daysStandard: New Badge ($12 Fee) received 7-10 business daysNext Wear Period: New badge received with next regular badge shipment
New badge will be sent back with normal badge return shipments, and next badge received with next wear period shipment
Standard BodyOther

Add Badge - Other
Additional/New Control BadgeArea MonitorOther
If "Other", please specify badge type:*
A Penn VET RDC Customer Care Representative will be in touch for more information. Please provide your preferred contact information below.
Email
example@example.com
Phone Number

Area CodePhone Number

Deactivate Badge - Unaffiliated Employee

Please fill out the unaffiliated employee's information below.
Name*

First NameLast Name
Last Day of Employement*

MonthDayYear
Date

Add Fetal Badge - Pregnant Employee

Please fill out the pregnant employee's information below.
Name*

First NameLast Name
Employee's Date of Birth*

MonthDayYear
Date
YesNo
Rush ($50 additional fee) 1-2 business daysStandard: New Badge ($12 Fee) received 7-10 business daysNext Wear Period: New badge received with next regular badge shipment
Last Month that the Fetal Badge will be needed:*
Important: Please be sure that you read the "Fetal Badge" section of the Radiation Badge FAQ (will link we have it ready) if you have not already.

Add Badge - New Employee