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
Sani-Cloth Disinfectant Wipes
Bleach Wipes
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

FYI: Lab tubes are unable to be sent at this time. Please pick these up from the office or labortories until further notice. Thank you for your understanding!

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
Intermittent catheter Tray
Trach Sputum Collection
Specimen Bags (pk of 100)
STAT Specimen bags (pk of 100)
Lab Labels (roll)
Wound Culture Swab

Phlebotomy Specimen Collection

	Amount Needed	Notes
Red Top Tubes (tray)
Gold SST (tray)
Blue Top Tubes (tray)
Mint Green PST (tray)
Lavender Top (tray)
Tiger Top UA Tubes (tray)
Urine Culture Kit (box)
Specimen Cups (each)
Specimen Hat (each)
Clean Catch Wipes (box)
Straight Needles (box)
Butterfly Needles (box)
Hypodermic Needle (each)
10cc Syringe (each)
Female adaptors (each)
Male adaptors (each)
Tube Holder (bag)
2x2 Gauze (box)
Band-aid (box)
alcohol pad (box)
Tourniquet (box)
Specimen Bags (pk of 100)
STAT Specimen bags (pk of 100)
Lab Labels (roll)

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

OC & DS: MISC

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