Clinical Supplies Order Form

Clinical Supplies Order Form
Client Information
Clinic Name*
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Full Name*
Email Address*
Phone*

Area CodePhone Number
Fax

Area CodePhone Number
Ground (3 - 5 Business Days)Express (Overnight)
Sales Representative*
Sales Rep Email
example@example.com
I want to put this order on Automatic Monthly Recurring Shipments

Page 2
DermatologyPodiatryGI/Endoscopy CenterUrology ClinicOncology PracticeHospital/Surgery CenterImaging CenterOther (i.e. Multi-Specialty Clinic, Family Practice, etc.)
Formalin BottlesMichels SolutionKitsCulturesCollection Bags/ContainersRequisitionsCourier/Shipment SuppliesPrinted Materials
- 7 mL20 mL40 mL60 mL90 mL120 mL240 mL500 mL
- 7 mL Formalin Bottles
- # of vials (7 mL)
- 20 mL Formalin Bottles
- Box of 24 VialsCase of 96 Vials
- # of boxes (20 mL)*
  Please remember that each box contains 24 vials
- # of cases (20 mL)*
  Please remember that each case contains 96 vials
- 40 mL Formalin Bottles
- Box of 24 VialsCase of 96 Vials
- # of boxes (40 mL)*
  Please remember that each box contains 24 vials
- # of cases (40 mL)*
  Please remember that each case contains 96 vials
- 60 mL Formalin Bottles
- Box of 24 VialsCase of 96 Vials
- # of boxes (60 mL)*
  Please remember that each box contains 24 vials
- # of cases (60 mL)*
  Please remember that each case contains 96 vials
- 90 mL Formalin Bottles
- Box of 24 VialsCase of 96 Vials
- # of boxes (90 mL)*
  Please remember that each box contains 24 vials
- # of cases (90 mL)*
  Please remember that each case contains 96 vials
- 120 mL Formalin Bottles
- # of vials (120 mL)
- 240 mL Formalin Bottles
- # of vials (240 mL)
- 500 mL Formalin Bottles
- # of vials (500 mL)
- Michels soution not available for your type of practice.
- # of vials (20 mL - Michels)
- No kits available for your type of practice.
- ENFD Kit
- # of ENFD kits
- Prostate Kit with Cassettes
- # of Prostate Kits with Cassettes
- 16 Vial Prostate Kit
- # of 16 Vial Prostate Kits
- Prostate Biopsy Kit with 12-site Universal Board
- # of Prostate Biopsy Kit with 12-site Universal Board
- Prostate Biopsy Kit with 12-site Bx Board
- # of Prostate Biopsy Kits with 12-site 2-Board
- # of Prostate Biopsy Kits with 12-site 3-Board
- Bone Marrow Kit
- # of Bone Marrow Kits
- Peripheral Blood Kit
- # of Peripheral Blood Kits
- Urine Molecular Kit
- # of Urine Molecular Kits
- RPP Kit
- # of RPP kits
- Bladder Fish Kit
- # of Bladder Fish kits
- No cultures available for your type of practice.
- Aerobic
- # of aerobic cultures
- Anaerobic
- # of anaerobic cultures
- Eswabs
- Single swabs (up to 49)Pack of 50 swabs
- # of eswabs
  Please note the maximum you can order is 49
- Pack of 50 Eswabs
  Please note that you can only order 1 a maximum of one pack at a time
- Luer Lock Tip Syringe Caps
- # of Luer Lock Tip Syringe Caps
  Please note the maximum you can order is 250
- 6 x 9 Biohazard Bags (Packs of 100)
- # of 6 x 9 biohazard bag packs
  Maximum order is 5 (packs of 100)
- Large Transport Bag (White)
- # of large transport bags (white)
  Maximum order is 30 bags
- Surgical Biohazard Transport Bag
- # of surgical biohazard transport bags
  Maximum order is 30 bags
- 3 x 5 Nail Bags
- Single bags (up to 99)Pack of 100 bags
- # of 3 x 5 nail bags
- # of 3 x 5 nail bag packs (100 bags/pack)
  Maximum order is 5 (packs of 100)
- 4 x 6 Nail Bags
- Single bags (up to 99)Pack of 100 bags
- # of 4 x 6 nail bags
- # of 4 x 6 nail bag packs (100 bags/pack)
  Maximum order is 5 (packs of 100)
- 16 oz Specimen Tubs
- # of 16 oz specimen tubs
- 24 oz Specimen Tubs
- # of 24 oz specimen tubs
- 64 oz Specimen Tubs
- # of 64 oz specimen tubs
- 1 Gallon Specimen Tubs
- # of 1 gal specimen tubs
- Sterile Cups
- # of sterile cups
- 20 mL Specimen Cups
- # of 20 mL specimen cups
- Dermatopathology Requisitions
- Podiatric Pathology Requisitions
- Surgical Pathology Requisitions
- Urologic Pathology Requisitions
- Gastroenterology Requisitions
- Non-Gyn Cytology Requisitions
- Hematology/Oncology Requisitions
- Logbooks
  Please note that 1 book has 50 pages
- EMA Paper (250 pages/ream)
  Maximum order is 4 reams
- Sagis Standard Lockbox (Single with Combination Lock)FedExUPSSWA CargoIce Packs
- Sagis Standard Lockbox (Single with Combination Lock)
- 8 x 12 x 3.5" (Hanging)14 x 14 x 7" (Hanging)16 x 19.5 x 7" (Hanging)11 x 14 x 7" (Floor)14 x 13 x 12" (Floor)15 x 24 x 12" (Floor with chute)
- HangingFloor
- # of 8 x 12 x 3.5" (Hanging) Lockbox(es)
- # of 14 x 14 x 7" (Hanging) Lockbox(es)
- # of 16 x 19.5 x 7" (Hanging) Lockbox(es)
- # of 11 x 14 x 7" (Floor) Lockbox(es)
- # of 14 x 13 x 12" (Floor) Lockbox(es)
- # of 15 x 24 x 12" (Floor with chute) Lockbox(es)
- Fedex
- Medium Clinical BoxLarge Clinical BoxClinical PacksReturn Labels (no boxes needed)
- FedEx - # of Single Boxes (Medium Clinical Box)
  Please note that boxes are ordered in quantities of 10 (max 50)
- FedEx - # of Single Boxes (Large Clinical Box)
  Please note that boxes are ordered in quantities of 10 (max 50)
- FedEx - # of Single Packs (Clinical Packs)
  Please note that boxes are ordered in quantities of 10 (max 50)
- FedEx - # of Return Labels
  Please note this number is automatically calculated by the number of boxes ordered. If you need additional labels, please note that in the comments section at the end of the form.
- Default Address (provided on page 1 of this form)Other Address
- From Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- UPS
- Medium Clinical BoxLarge Clinical BoxClinical PacksReturn Labels (no boxes needed)
- UPS - # of Single Boxes (Medium Clinical Box)
  Please note that boxes are ordered in quantities of 10 (max 50)
- UPS - # of Single Boxes (Large Clinical Box)
  Please note that boxes are ordered in quantities of 10 (max 50)
- UPS - # of Single Boxes (Clinical Packs)
  Please note that boxes are ordered in quantities of 10 (max 50)
- UPS - # of Return Labels
  Please note this number is automatically calculated by the number of boxes ordered. If you need additional labels, please note that in the comments section at the end of the form.
- Default Address (provided on page 1 of this form)Other Address
- From Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- SWA Cargo
- 12 x 12 x 9 Specimen Boxes (Packs of 25)16 x 12 x 6 Slide Boxes (Packs of 25)
- # of 12 x 12 x 9 Specimen Box Packs
  Please remember that these come in packs of 25
- # of 16 x 12 x 6 Slide Box Packs
  Please remember that these come in packs of 25
- Ice Packs
- # of single ice packs
- Billing Overview Sheet pads
- # of Billing Overview Sheet - English pads
  Each pad contains 25 Billing Overview Sheets
- # of Billing Overview Sheet - Spanish pads
  Each pad contains 25 Billing Overview Sheets
- Clinical Photo Submission QR Code Sticker
  Can be ordered as a single sticker
- Explanation of Services
- # of Explanation of Services - English pads
  Each pad contains 25 Explanation of Services Sheets
- Paper Wound Measuring Guide
- # of Paper Wound Measuring Guide pads
  Each pad contains 50 Wound Measuring Guides
- Patient Information Brochures
  
  Each pack contains 25 patient information brochures
- # of Melanoma - English packs
  Each pack contains 25 brochures
- # of Melanoma - Spanish packs
  Each pack contains 25 brochures
- # of Seborrheic Keratosis – English packs
  Each pack contains 25 brochures
- # of Seborrheic Keratosis - Spanish packs
  Each pack contains 25 brochures
- # of Squamous Cell Carcinoma- English packs
  Each pack contains 25 brochures
- # of Squamous Cell Carcinoma - Spanish packs
  Each pack contains 25 brochures
- # of Actinic Keratosis – English packs
  Each pack contains 25 brochures
- # of Actinic Keratosis - Spanish packs
  Each pack contains 25 brochures
- # of Basal Cell Carcinoma - English packs
  Each pack contains 25 brochures
- # of Basal Cell Carcinoma - Spanish packs
  Each pack contains 25 brochures
- # of ABCDE Skin Care – English packs
  Each pack contains 25 brochures
- # of ABCDE Skin Care - Spanish packs
  Each pack contains 25 brochures
- # of Small Fiber Neuropathy - English packs
  Each pack contains 25 brochures
- Comments
- Should be Empty:

Clinical Supplies Order Form

Client Information

7 mL Formalin Bottles

20 mL Formalin Bottles

40 mL Formalin Bottles

60 mL Formalin Bottles

90 mL Formalin Bottles

120 mL Formalin Bottles

240 mL Formalin Bottles

500 mL Formalin Bottles

ENFD Kit

Prostate Kit with Cassettes

16 Vial Prostate Kit

Prostate Biopsy Kit with 12-site Universal Board

Prostate Biopsy Kit with 12-site Bx Board

Bone Marrow Kit

Peripheral Blood Kit

Urine Molecular Kit

RPP Kit

Bladder Fish Kit

Aerobic

Anaerobic

Eswabs

Luer Lock Tip Syringe Caps

6 x 9 Biohazard Bags (Packs of 100)

Large Transport Bag (White)

Surgical Biohazard Transport Bag

3 x 5 Nail Bags

4 x 6 Nail Bags

16 oz Specimen Tubs

24 oz Specimen Tubs

64 oz Specimen Tubs

1 Gallon Specimen Tubs

Sterile Cups

20 mL Specimen Cups

Sagis Standard Lockbox (Single with Combination Lock)

Fedex

UPS

SWA Cargo

Ice Packs

Billing Overview Sheet pads

Explanation of Services

Paper Wound Measuring Guide

Patient Information Brochures