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Name of Requestor
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Requestor Phone
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Area Code
Phone Number
Deliver To:
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Street Address
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Facility Type/Division
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Skilled Nursing
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Route (if known)
ELGIN (NB-ELGIN)
IND
KANKAKEE
MCH
CHICAGO N (NBNEL)
CHICAGO S (NBCS)
NBK N (NBN)
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NBK W (NBW)
PEO
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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 Kits
$
Free
Urinalysis and UA/C&S
Quantity
24-Hour Urine Containers
$
Free
Drug screen cups (green lid)
$
Free
Blood Collection Tubes
$
Free
Please select type(s): PR (red top), BL (light blue top), SST (gold/tiger top), LAV (lavender top)
Select Type:
PR (red top)
BL (blue top)
SST (gold/tiger top)
LAV (lavender top)
Select if second type needed:
n/a
PR (red top)
BL (blue top)
SST (gold/tiger top)
LAV (lavender top)
Select if third type needed:
n/a
PR (red top)
BL (blue top)
SST (gold/tiger top)
LAV (lavender top)
Select if fourth type needed:
n/a
PR (red top)
BL (blue top)
SST (gold/tiger top)
LAV (lavender top)
Culturette (pink cap)
$
Free
Wound/Bacterial culture
Quantity
M4RT w/ Nasopharyngeal swab (red cap)
$
Free
Respiratory panel, COVID, Flu A/B, RSV
Quantity
Scabies Kit
$
Free
Includes microscope slides (2) and lancet.
Hemoccult Slides
$
Free
REQUISITION FORMS
Requisition Forms - blank
$
Free
Requisition Forms - COVID/Respiratory
$
Free
Drug Screen COC Forms
$
Free
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.
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