Supply Order Form

Client Information
Client name*
Client Email
Client No*
Phone No*
Date requested*
MM slash DD slash YYYY
Date needed*
MM slash DD slash YYYY
Ordered by
Your Order
Tubes
- Tubes
364606 ACD Solution A Yellow (ea)
368380 Dark Blue No Additive (ea)
368381 Dark Blue EDTA (ea)
367925 Gray 7 mL (Sodium Fluoride) (ea)
367871 Green tubes 4 mL Na Heparin (ea)
367874 Green 10 mL Na Heparin (ea)
367863 Lavender 6 mL (ea)
364861 Lavender EDTA 4 mL (ea)
367988 SST 8.5 mL (ea)
Amber Plastic Vials/Caps (50/bag)
Blood Serotonin Tubes (ea)
Pyruvate/Lactate Tubes – (3 tubes/2 weeks) (ea)
Serum Transport Tubes/Caps (1000/bag)
Protease Inhibitor Tube (ea)
Salivary cortisol tubes (ea)
QVAL trace element serum tube (red label) (ea)
QVAL trace element blood tube (lav label) (ea)
366430 Red-top serum tubes, 10 mL (ea)
ARUP metal-free tubes (blue cap) (ea)
Bags
- Bags
8 x 10 Sample Specimen –Room Temperature (100/pk)
8 x 10 Sample Specimen -Refrigerate (100/pk)
8 x 10 Sample Specimen -Frozen (100/pk)
13 x 15 Zip Lock TRANSPORT -Room Temp (100/pk)
13 x 15 Zip Lock TRANSPORT -Refrigerate (100/pk)
13 x 15 Zip Lock TRANSPORT -Frozen (100/pk)
Sample Transport Boxes (400/cs)
Absorbent shipping pads (100/pk)
Microbiology/virology
- Microbiology/virology
Alinity Collection Kits (50/box)
Aptima® Collection Kits – Gen Probe (purple) (50/box)
Aptima® Urine Collection Kits-Gen Probe (Yellow) (50/box)
Aptima® transfer tube (green) (ea)
Aptima® Multitest Collection Kit (Orange Label) (ea)
Bordetella-Pertussis media (3 tubes/2 weeks) (ea)
M-4 Media RT (ea)
Mycoplasma/Ureaplasma Media (UTM-RT) – Lesion (ea)
Mycoplasma/Ureaplasma Media (UTM-RT) – Nasal (ea)
Mycoplasma/Ureaplasma Media (UTM-RT) – Vaginal/Cervix (ea)
Mycoplasma/Ureaplasma Media (UTM-RT) – Male, Urethral (ea)
Ova & Parasite Kit (Total-Fix) (25/box)
Quantiferon Plus (4 tube) kit (ea)
Tissue transport media
- Tissue transport media
Flow Cytometry-MEM (ea)
Tissue Transport Media –(5 tubes/2 weeks) (ea)
Urine containers
- Urine containers
24 Hour Urine Bottles (50/box)
Urine Cups/Green Cap (50/bag)
Chain of Custody Kits (FT) (100/box)
24 hr urine bottles – acid washed (ea)
50 mL acid wash tubes – urine (5 each/month) (ea)
Printer supplies
- Printer supplies
Toner cartridge (ea)
Toner cartridge model number*
Zebra Barcode Labels (5000/roll)
Requisitions, Test (1000/box) (ea)
Chain of Custody Requisitions (FT) (500/box) (ea)
Cystic Fibrosis Brochure English/Spanish (25 pkg)
Serum Integrated Test English/Spanish (25 pkg)
Quad Test English/Spanish (25 pkg)
Full Integrated Test Brochure English/Spanish (25 pkg)
First Trimester Scrn Brochure English/Spanish (25 pkg)
Sequential Screen Brochure English/Spanish (25 pkg)
Sequential Screen Brochure English/Spanish (25 pkg)
Prenatal Information Sheets (ea)
Autopsy Chain of Custody requisitions (ea)
Panorama patient brochure (ea)
Miscellaneous
- Miscellaneous
Boric Acid Tablets (1 gram each) (50/bag)
Stool Containers (ea)
UroVysion Kits (5 kits/week) (ea)
Stone Risk Kits (ea)
Panoroma kits (ea)
Urine pyrrole tubes (ea)
H. pylori breath kits (ea)
H. pylori sterile cups, green cap (10/bag)
Hydrogen breath kits/Bacterial overgrowth (ea)
ThinPrep Vial (25/pack)
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