NICL Supplies Request Form

Name of Facility
Name of Requestor

First NameLast Name
Requestor Phone

Area CodePhone Number
Deliver To:

Floor/Unit/Area

Street Address

CityState

Zip Code
Facility Type/Division

Other
Route (if known)
Select region
Acct. No. (if known)
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COLLECTION SUPPLIES

REQUISITION FORMS

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COLLECTION SUPPLIES

Specimen cups (orange cap)Free
Stool, Sputum, UA / Urine chemistry

Quantity

Complete Urine Culture KitsFree
Urinalysis and UA/C&S

Quantity

24-Hour Urine ContainersFree

Drug screen cups (green lid)Free

Blood Collection TubesFree
Please select type(s): PR (red top), BL (light blue top), SST (gold/tiger top), LAV (lavender top)

Select Type:Select if second type needed:Select if third type needed:Select if fourth type needed:

Culturette (pink or blue cap)Free
Wound/Bacterial culture

Quantity

M4RT w/ Nasopharyngeal swab (red cap)Free
Respiratory panel, COVID, Flu A/B, RSV

Quantity

Scabies KitFree
Includes microscope slides (2) and lancet.

Hemoccult SlidesFree

REQUISITION FORMS

Requisition Forms - blankFree

Requisition Forms - COVID/RespiratoryFree

Drug Screen COC FormsFree

OTHER

Fax Toner (specify Model # in notes below)Free

Fax Drum (specify Model # in notes below)Free

Other Item (specify in notes below)Free
Notes
*Quantity for all supplies: We will provide our standard batch sizes. If additional quantity is needed, please specify here.
- Delivery By
  Full Name
- Date Delivered
  
  MonthDayYear
- Delivery Confirmation
- Should be Empty:

*