Name of Facility
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Name of Requestor
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First Name
Last Name
Requestor Phone
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Area Code
Phone Number
Deliver To:
Floor/Unit/Area
Street Address
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State
Zip Code
Facility Type/Division
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Skilled Nursing
Assisted Living
Unspecified
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Route (if known)
ELGIN (NB-ELGIN)
IND
KANKAKEE
MCH
CHICAGO N (NBNEL)
CHICAGO S (NBCS)
NBK N (NBN)
NBK S (NBCC)
NBK W (NBW)
PEO
RFD
WBK Central (WBC)
WBK S (WBS)
WBK SW (WBSW)
WBK W (WBW)
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Acct. No. (if known)
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COLLECTION SUPPLIES
REQUISITION FORMS
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COLLECTION SUPPLIES
Specimen cups (orange lid)
$
Free
Complete Urine Kits (UA + culture)
$
Free
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)
Swabs - COVID
$
Free
Quantity Requested
Swabs - Influenza
$
Free
Swabs - Pink Culturette
$
Free
Swabs - M4RT
$
Free
Scabies Kit
$
Free
Includes microscope slides (2) and lancet.
Hemoccult Slides
$
Free
REQUISITION FORMS
Requisition Forms - blank
$
Free
Requisition Forms - red/pink (standing order/ASOS)
$
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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Delivery By
Full Name
Date Delivered
/
Month
/
Day
Year
Delivery Confirmation
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