Supply Order Form - Coast Diagnostics

Email Sender Name
Used for Submission/Notification Email Purposes
IMPORTANT Federal and State Law mandates that Clinical Laboratories may give clients only those supplies directly related to the collection of specimens and in amounts proportionate to specimens received from the client. Supply orders are processed Monday – Friday from 8:00AM – 3:00PM. Please allow 24 - 36 hours for supply requests to be filled. Specimen Bags are included with all collection kit/device orders: (1) specimen bag per (1) media unit.
- Name:*
  
  First NameLast Name
- Email:*
  example@example.com
- Facility Name:*
  Specify which clinic if the facility has multiple locations.
- Request Date:*
  
  MonthDayYear
  MM/DD/YYYY
- Directly to FacilityEmployee Residence
- Delivery Method:*
  "Courier (EMERGENCY ONLY)" option applies to Courier-based accounts only; please contact your Territory Manager for more information.
- Employee:*
- ATTN:
- Delivery Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Any additional comments, notes, providers (prefilled requisitions), or requests regarding this Supply Order can be made on the following page under the Additional Information section.

RPPEENTGISTIHerpesVaginitisCOVID
Kit SuppliesBulk Supplies
Respiratory Pathogen Panel

RPP
Option #1: Dasky Kit*
Quantity | Order as Kit [1 kit = 50 swabs, tubes, bags]
eSwab™ Pack (White Cap)*
Quantity | Order as Each
COVID-19 RT-PCR

COVID-19
Option #1: Dasky Kit*
Quantity | Order as Kit [1 kit = 50 swabs, tubes, bags]
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Eye, Ear, Nose, & Throat Panel

EENT
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Gastrointestinal Panel

GI
FecalSwab® Pack (Orange Cap)
Quantity | Order as Each
FecalSwab® Pack (Green Cap)
Quantity | Order as Each
Urinary Tract Infection Panel

UTI
Option #1: UTI/PCR - Flocked Swab Pack*
Quantity | Order as Each
Option #2: UTI/PCR - UA and C&S Tubes w/ Integrated Transfer*
Quantity | Order as Each
Option #3: UTI/PCR - C&S Tube with Integrated Transfer*
Quantity | Order as Each
Option #4: UTI/PCR, UA, and C&S - CCM Tube with Integrated Transfer*
Quantity | Order as Each
Sexually Transmitted Infection by PCR

STI
Option #1: STI Urine Kit - C&S Tube with Integrated Transfer*
Quantity | Order as Each
Option #2: eSwab™ Pack (White Cap)*
Quantity | Order as Each
Option #3: CCM Tube with Integrated Transfer*
Quantity | Order as Each
Herpes Panel

Herpes
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Vaginitis with STI

Vaginitis w/ STI
Option #1: eSwab™ Pack (White Cap)*
Quantity | Order as Each
Option #2: C&S Tube with Integrated Transfer*
Quantity | Order as Each
Fungal Panel

Fungal
Translucent Tube & Alcohol Pad*
Quantity | Order as Each

URINE - C&S Tube with Integrated TransferWOUND - eSwab™ Pack (White Cap)
URINE - C&S Tube with Integrated Transfer*
Quantity | Order as Each
WOUND - eSwab™ Pack (White Cap)*
Quantity | Order as Each

Specimen Container - 3 oz with Temperature Strip
Specimen Container - 3 oz with Temperature Strip*
Quantity | Order as Each

By signing below, I acknowledge that I have completed this Supply Order Form to the best of my ability and have communicated all details regarding this order with the Supply department via online submission and/or email (if necessary).

Should the recipient not receive the requested supplies within 48 hours, I understand it will be my responsibility to contact the Supply department via email (supplies@coastdiagnostics.com) to alert them of any missing supply items.
I checking 'I Agree', I acknowledge that I have completed this Supply Order Form to the best of my ability and have communicated all details regarding this order with the Supply department via online submission and/or email (if necessary). Should the recipient not receive the requested supplies within 48 hours, I understand it will be my responsibility to contact the Supply department via email (supplies@coastdiagnostics.com) to alert them of any missing supply items.*

I Agree
Requestor Signature:*

Clear
Acknowledgment Signature

To request prefilled requisition forms for additional Providers, the following information is required:

First & Last Name - NPI Number

ex: Dr. John Doe - 0123456789

Please Note: Prefilled requisition forms will not be sent for a Provider if any of their specific information above is missing.

This information can be submitted in the Additional Notes or Comments field below.

Additional Items or Notes:

*This form is automatically sent to supplies@coastdiagnostics.com upon submission.
Should be Empty:

Preview Molecular Requisition Form	Preview Wellness Requisition Form
Preview Core Requisition Form	Preview Toxicology Requisition Form

Respiratory Pathogen Panel

COVID-19 RT-PCR

Eye, Ear, Nose, & Throat Panel

Gastrointestinal Panel

Urinary Tract Infection Panel

Sexually Transmitted Infection by PCR

Herpes Panel

Vaginitis with STI

Fungal Panel