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)
What type of change would you like to request? (You may select multiple)

Add Badge - New Employee
New Employee's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Start Date:
New badge will be sent back with normal badge return shipments, and next badge received with next wear period shipment
Badge Type:

Other

Add Badge - Other
What type of Badge are you requesting?
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
Is this employee currently assigned a dosimetry badge?
Badge Shipping:
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