Trunk Stock Supply Request

Care type*

HomecareHospice

Type of Clinician*

Name*

First NameLast Name

Email*

example@example.com

Clinician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Order date*

Date

What type of Trunk stock do you need to order?

Basic Nurse Supplies (Gloves, BP cuffs, bag barriers, ect)Specimen Collection (Needles, Cups, hats, bandaids ect)Urology Supplies (Catheters, Drainage bags, Insertion Kits, ect)Wound Care Supplies (Gauze, Cotton tipped Applicators, Wound rulers, ect)

On-Call & Day Shift: What type of Trunk stock do you need to order?

Basic Nurse Supplies (Gloves, BP cuffs, bag barriers, ect)Specimen Collection (Needles, Cups, hats, ect)Urology Supplies (Catheters, Drainage bags, Insertion Kits, ect)Wound Care Supplies (Gauze, Cotton tipped Applicators, Wound rulers, ect)MISC

Aide/Phlebotomy: What type of Trunk stock do you need to order?

Basic Supplies (Gloves, hand sanitizer, bag barriers, ect)Specimen Collection (Needles, Cups, hats, ect)

FYI: SOC packets, Med Planners, Cups, Lysol Wipes, Gowns, Booties/Boot covers, masks, printer paper and bug spray all need to be picked up from the office. Thank you!

Basic Nursing Supplies

	Size	Amount Needed	Notes
Exam Gloves
BP Cuff
Stethoscope
Weight Scale
Thermometer
Thermometer covers
Pulse Ox (Adult & Ped)
Bag Barriers
Hand Sanitizer
Hand Soap
Disinfectant Wipes (Container)
Bleach Wipes (Individual Packets)
Sterile Gloves
Baby Scale
Pediatric BP Cuff
Infant BP cuff

Basic Supplies

	Size	Amount Needed	Notes
Exam Gloves
Extended Cuff Gloves
Bag Barriers
Hand Sanitizer
Hand Soap
Sani-Cloth Disinfectant Wipes
Bleach Wipes

Specimen Collection

	Amount Needed	Notes
Specimen Cups
Speciman Hat
Clean Catch Wipes
Straight Needles
Butterfly Needles
Hypodermic Needles
10cc Syringe
Female adaptors
Male adaptors
Tube Holder
2x2 Gauze (box)
Band-aid (box)
alcohol pad (box)
Tourinquet
Sharps Container
Specimen Bags (pk of 100)
STAT Specimen bags (pk of 100)
Lab Labels (roll)
Intermittent catheter Tray
Trach Sputum Collection
Wound Culture Swab

Blood & Urine Tubes

	Amount Needed	Notes
Red Top/ No additive
Navy Top No Additive/ Serum (Red)
Gold SST
Blue Top Tubes- Full Draw
Blue Top Tubes- Peds Draw
Mint Green PST
Lavender Top
Navy Top EDTA (Purple)
Tiger Top UA Tubes
Urine Culture Kit

Urology Supplies

	Latex Free	French Size	Amount Needed	Notes
Catheter Foley 2-way
Catheter Foley 2-way
Catheter Foley 2-way
Catheter Foley 2-way
Insertion Tray
Leg Bag 900mL
Drainage Bag 2000mL
Piston Syringe
Intermittent Catheter Tray
10cc Syringe (bx)
Iodine Swabs (bx)
Split 4x4 Gauze (bx)

Wound Care Supplies

	Amount Needed	Notes
ABD Pads 5X9 (bx)
Adaptic 3X8
Adhesive Remover (bx)
Cotton Tipped Applicators (bx)
Elastic Bandages 4"
Iodine Swabs (bx)
Normal Saline 100mL
Paper Tape 2"
Plastic Tape 2"
Roll Gauze/Kerlix
Skin Barrier Wipes (bx)
Split Gauze 4X4 (bx)
Staple Removal Tray
Sterile Non-Woven Gauze 4x4 (bx)
Sterile Non-Woven Gauze 2x2 (bx)
Sterile Woven Gauze 4x4 (bx)
Suture Removal Tray
Wound Culture Swab
Wound Rulers (pad)
Xeroform 5X9

OC & DS: MISC

	Amount Needed	Notes
O2 Tubing
Christmas Tree (O2)
O2 Mask
Nasal Cannulas
10mL Saline Flush
Leg Strap Foley Holder
Steri-Strips