Supply Order Form

Supply Order Form

Blood Tubes

10.ml Plain Red
9.5ml SST
4.0ml Lavender
5.0ml Light Blue
7.0ml Gray
4.5ml SST
Pedi Red
Pedi Lavender
Pedi Blue
Red Microtainer
Lav Microtainer
SST Microtainer

Needles

20 X 1"
20 X 1 1/2"
21 X 1"
21 X 1 1/2"
22 X 1"
22 X 1 1/2"
21G Butterflies
23G Butterflies
25 G Butterflies
Lancets

Gloves Latex

Small
Medium
Large

Gloves Vinyl

Small
Medium
Large

Urinalysis

Plastic Cups (100 pack)
Sterile Containers
Urine Analysis Tube (with pill)
Urine Culture/Sens. Tube
24 Hour Urine Jugs

Cytology

Thin Preps (25 pack)
Cyto Brushes
Cyto Brooms
Plastic Spatulas
Fixative Spray
Gen-Probes Male
Gen-Probes Female

Stool Specimen

Stool O&P Kits (2 bottles)
Hemoccult Cards 3 Slides

Glucose beverages

50 Gram Orange
100 Gram Orange
75 Gram Orange

Miscellaneous

2X2 Gauze Pads
4X4 Gauze Pads
Alcohol Preps
Band-Aides
Tourniquets
Needle holder

Paper/Forms

General Test Requisition (2 Ply)
White Copy Paper (1 ream Pack)
Supply request forms (this form)

Bags

Specimen small (100 pack)
Transport Large bags

Toner & Ink

Please specify Make/Model or cartridge

Additional Items:

Your Information:

Requested By:
Doctor / Office Name:
Account #:
Address:
E-mail Address:

Additional Information or Special Instructions