Supply Order Form

Supply Order Form
All orders received on Mon, Fri will go out Tuesday; Orders received on Tue will go out Wednesday; Orders received on Wed, Thurs will go out Friday; Please allow 2-3 business days
TEL: (267)-212-2000 | FAX: (267)-212-2005
Date

Month Day Year
Date
Doctor/Practice:
Phlebotomist
Address
Phone Number
Blood Collection Tubes

100/PK Serum Seperator Tube 100/PK Red Top Tube 50/PK Lavendar Top Tube 100/PK Light Blue Top Tube 100/PK Navi Blue Top Tube/ W Purple Strip 100/PK Grey Top Tube 1/EA TB Gold
Needle supplies

48/Box Vacutainer Needles 48/Box Vacutainer Needles 25/PK Needle Holder (Needle Hubs) 1/EA Sharps Container
Urine Collection Tubes

100/PK Red/Yellow Top Tube 25/PK Amber Tube (UTI Testing) 25/PK Transport Tube 1/EA Urine Culture & Sensitivity Kit
Urine Collection

25/PK Sterile Urine Cup 1/EA 24 Hr Urine Container
Shipping Supplies

48/Box Ice Packs 1/EA Padded Packs 10/PK FedEx Labels 10/PK FedEx Shipping Bags 20/PK FedEx Shipping Boxes
Stool Collection

1/EA Tri-Slide Occult Blood Detection Kit 1/EA Stool Culture & Sensitivity Kit
Swab Collection

1/EA Molecular Collection Kit (Includes Buccal Swab, Silica, Sleeves) 1/EA RPP Swab 100/PK COVID19 Test Kits
Requisitions

25/PK Clinical Requisitions 25/PK Toxicology Requisitions 25/PK PGx Requisitions 25/PK CGx Requisitions 25/PK Cardio Requisition 25/PK Pulmonary Requisition 25/PK OB/Gyn Requisition
Miscellaneous Supplies

100/PK Bandages 200/PK Alcohol Prep Pads 200/PK GauzeSponge 2x2 25/PK Tourniquets 100/PK Safeguard Specimen Pack 200/PK Small Gloves 200/PK Medium Gloves 180/PK Large Gloves 5/PK H-Pylori Breath Kit 1/EA Glucose Drink 1/EA Formalin Jars 25/PK ThinPrep Collection Kits (Vials, Brushes, Spatulas)
Additional Comments/Supplies
The supplies provided by our company are to be used solely for the collection and preparation of specimens to be sent to Genesis Diagnostics for testing. These supplies are not intended for any other uses, and such a limitation is necessary to comply with applicable laws. Your acceptance of supplies provided by Genesis Diagnostics constitutes acknowledgement and agreement to these terms and conditions.
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