Supply Requisition Form

Dynacare Supply Order Form
Clinic Name*
Physician OHIP Billing*
Address*
Date*
Telephone*
Format: (000) 000-0000.
Requested by*
- Please enter the Name of the product and Quantity you need.
- GREY Vacutainer 2mL, Hemoguard Plastic (Each)
- GREEN Vacutainer 6mL, Hemoguard Plastic (Each)
- PINK Vacutainer 6mL, K2EDTA, Hemoguard Plastic (Each)
- RED Vacutainer 10mL, Plastic (Each)
- ROYAL BLUE Vacutainer 6mL, K2EDTA, Hemoguard Plastic (Each)
- RED Vacutainer 4mL, Hemoguard Plastic (Each)
- GREY Vacutainer 6mL, K2EDTA, Hemoguard Plastic (Each)
- LIGHT BLUE Vacutainer 2.7mL, Hemoguard Plastic (Pk-100)
- MAUVE Vacutainer 4mL, Hemoguard Plastic (Pk-100)
- Vacutainer SST 5mL, Hemoguard Plastic (Pk-100)
- Tourniquet Latex-Free (Pk-25)
- 21 G X 1 1/4" Multisample Needle w Saf-T Lok (Bx-48)
- 22 G X 1 1/4" Multisample Needle w Saf-T Lok (Bx-48)
- Adult Needle Holder- single use T (Pk-10)
- 50% Ethanol 30mL (Urine/sputum Cytology) (Bottle)
- Ziploc® Bag 5 x 8 (Pk-100)
- Ziploc® Bag 6 x 9 w Pouch (PK-50)
- Ziploc® Bag 8 x 10 (PK-100)
- HISTO Ziploc® Bag 6 x 9 (PK-100)
- Formalin 10% 30mL Bottle (Each)
- Formalin 10% 5mL Bottle (Each)
- Formalin 10% 90mL Bottle (Each)
- Fungal Kit
- Myco/Ureaplasma transport media & swab (Each)
- Pinworm Collection Bottle (Each)
- Copan Stool Collection Device C/S (Each)
- Stool O&P Bottle (Each)
- Swab Clear Amies (general culture) (Bag-50)
- Unisex Swab Aptima (STI-NAAT) (Each)
- Multitest Swab Aptima (STI-NAAT) (Each)
- Hologic® Pap Test Device -Vial & Broom (PK-25)
- Hologic® Pap Test -Broom ONLY (PK-25)
- CYTOBRUSH & SPATULA COLLECTION DEVICE (PK-25)
- Urine Bottle 24 HR 3L (Each)
- Urine Bottle 24 HR with 25mL Acid (Each)
- Urine Bottle Sterile 90mL (BG-100)
- Urea Breath / H. pylori (Kit)
- Urine Preservative Tube with Label (Each)
- 30mL FNA Cytolyt Bottles (Bottle)
- 24 Hour Urine (Each)
- Fungus Instruction (Each)
- Semen Analysis (Each)
- Sputum C&S (Each)
- Stool O&P (Each)
- Partner Supply Requisition (Each)
- Cytology Requisition (Each)
- Histopathology Requisition (Each)
- Returned Goods Form (Each)
- Pinless English Postcards (Pk-200)
- Pinless French Postcards (Pk-30)
- Absorbent Pad 3"x3" (Each)
- Glucose Challenge Drink Orange 50g (Bottle)
- Glucose Tolerance Drink Orange 75g (Bottle)
- Lactose 50g Powder in Bottle (Bottle)
- Immunofluorescence Bottles (Each)
- Pediatric Urine Container (Pk-10)
- Should be Empty:

Dynacare Supply Order Form