Medical Client Supply Form

Submitted by Admin on Tue, 2010-12-14 13:27

Source Facility #: *

Date: *

Client Name: *

Email: *

Client Address: *

City: *

State: *

Zip: *

Requested By: *

Client Phone #: *

Client Service Rep:

*Microbiology and Immunology Supplies (Order by EA Quantity)

Blood Culture Bottles

Pediatric 14443 EA:

Aerobic 14437 EA:

Anaerobic 14438 EA:

Fan 14431 EA:

Culturettes

Viral Swabies (viral cult) LIQ Stuart Flex 13814 EA:

Mini Tip 13798 EA:

Aerobic 13235 EA:

Anaerobic/Aerobic (wound) 11709 EA:

BD Universal Transport 3 mil with Flock Flex Mini Tip 91392 EA:

Stool Collection

Stool Cups 14125 EA:

O&P Kit Parapak (grey/pink lid) 14002 EA:

Stool Culture Parapak (orange lid) 13972 EA:

FIT / FOBT Test Kits 121197 EA:

GC/Chlamydia Kits

Aptima Combo 2 Unisex Swab 83528 EA:

Aptima Combo 2 Urine 83529 EA:

Herpes

BD Universal Transport 3ml with flock flex mini tip 91392 EA:

Cytology Supplies

Slide Fixative 13903 EA:

Slides (frosted) 15148 BX:

2 Slide Mailers 65394 EA:

Pap Kits

Brush Spatula Device 88655 EA:

Broom Device 88656 EA:

Sure Path Preservative Vials 88654 EA:

Digene Kit (PAP) 15485 EA:

Formalin Bottles

15 ML 14144 EA:

30 ML 14147 EA:

8 x 10 Biopsy/Tissue Transport Bag 15978 EA:

Miscellaneous Supplies

Shipping Boxes

12 x 12 x 4 box 15329 EA:

12 x 12 x 12 box 15326 EA:

Box W/Styro Liner 4/PK 15660/15661:

16 x 16 x 12 box 15324 EA:

5 x 5 x 5 box 15328 EA:

UN 3373 Labels EA (Limit 20):

9x6x3.5 Box 82669 EA:

Fed-Ex Air Bills EA 15930:

Fed-Ex Lab Packs EA 15931:

Fed-Ex Saturday Del Stickers:

Requisitions

15594 Test:

15593 Cyto/Path:

Phlebotomy Supplies

Needles

21G x 1" Safety 2073 48/BX:

22G x 1" Safety 2074 48/BX:

23G Lueradapt (butterfly) Safety 3203 EA:

21G Lueradapt (butterfly) Safety 14082 EA:

Tourniquets 13297 EA:

Needle Holders (Hubs)

Safety Holder (Hub) 9052 250 Ea Per Bag:

Tubes (50 to 1 Flat)

SST 5 ML Gold 48063 EA:

SST 8.5 ML 48058 EA:

Royal Blue (NaEDTA for Lead) 15133 EA:

Royal Blue (W/O HEPARIN) 13730 EA:

Plain Red 4 ML 48049 EA:

Plain Red 10 ML 48059 EA:

Lavender 3 ML 48051 EA:

Lavender 4 ML 48050 EA:

Green 7 ML (Na HEPARIN) 48062 EA:

Green 5 ML (LI HEPARIN for Ca) 48047 EA:

Green PST (LI HEPARIN) 48065 EA:

Yellow 8.5 ML SOL-A 14095 EA:

Yellow 6 ML (ACD) SOL-B 13829 EA:

Microtainer With K2 EDTA 8975 PK:

K2 EDTA 5 ML 15486 EA:

LT Blue 4.5 ML 88140 EA:

4 ML Grey 48052 EA:

Clear Serum Transport 27760 EA:

Caps for Serum Transport 14085 EA:

Amber Bullets (Peds) 99243 B:

Urine Supplies

24 Hour Container 5688 EA:

Sterile Cups 14200 EA:

C&S Urine Transport Kits 9399 EA:

Computer or Printer Supplies

DOH Mailing Boxes 82669 EA:

Brother 350 Drum 49852 EA:

Med 350 Toner Cartridge (Brother Fax) 28495 EA:

Glucola

Lime 100G 83563 EA:

Orange 50G 83565 EA:

Orange 100G 83564:

Fruit Punch 50G 90929 EA:

Other

Transport Pocket SED 89995 100/PK:

Red STAT Bags 14217 100/PK:

Blue Cold Bags (frozen) 14216 100/pk:

Ice Blanket 14567 EA:

Transport Pocket Yellow 14215 100/PK:

White Client Alert Bag 18928 100/PK:

Any Special Instructions: