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.

Mob: (267)-981-0960
Full Name*

First NameLast Name
Doctor/Practice: *
Phlebotomist *
Address*

Street Address

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
48/Box Vacutainer Needles48/Box Vacutainer Needles25/PK Needle Holder (Needle Hubs)1/EA Sharps Container
100/PK Red/Yellow Top Tube25/PK Amber Tube (UTI Testing)25/PK Transport Tube1/EA Urine Culture & Sensitivity Kit
25/PK Sterile Urine Cup1/EA 24 Hr Urine Container
48/Box Ice Packs1/EA Padded Packs10/PK FedEx Labels10/PK FedEx Shipping Bags20/PK FedEx Shipping Boxes
1/EA Tri-Slide Occult Blood Detection Kit1/EA Stool Culture & Sensitivity Kit
1/EA Molecular Collection Kit (Includes Buccal Swab, Silica, Sleeves)1/EA RPP Swab100/PK COVID19 Test Kits
25/PK Clinical Requisitions25/PK Toxicology Requisitions25/PK PGx Requisitions25/PK CGx Requisitions25/PK Cardio Requisition25/PK Pulmonary Requisition25/PK OB/Gyn Requisition
100/PK Serum Seperator Tube100/PK Red Top Tube50/PK Lavendar Top Tube100/PK Light Blue Top Tube100/PK Navi Blue Top Tube/ W Purple Strip100/PK Grey Top Tube1/EA TB Gold
100/PK Bandages200/PK Alcohol Prep Pads200/PK GauzeSponge 2x225/PK Tourniquets100/PK Safeguard Specimen Pack200/PK Small Gloves200/PK Medium Gloves180/PK Large Gloves5/PK H-Pylori Breath Kit1/EA Glucose Drink1/EA Formalin Jars25/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 Analitica Si 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 Analitica Si constitutes acknowledgement and agreement to these terms and conditions.
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