Dynacare Supply Order Form
Clinic Name
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Physician OHIP Billing
*
Address
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Date
*
Telephone
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Requested by
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Tubes
GREY Cap Glucose, PO/NaF, 2mL, 13x75 (Each)
GREEN Cap Plasma Sod Hep 6mL, 13x100 (Each)
PINK Cap EDTA K2, 6mL, 13X100 (Each)
ROYAL BLUE Na Hep Trace Element 6mL 13x100 (Each)
RED Cap Serum, Clot Activator, 9mL, 16x100 (Pk-50)
ROYAL BLUE 6mL K2EDTA Plastic w Hemagard (Each)
RED Cap Serum, Clot Activator, 4mL, 13x75 (Each)
GREY Cap Glucose, PO/NaF, 5.5mL, 13x100 (Pk-50)
BLUE Cap Sodium Citrate 3.2%, 2.7mL, 13x75 (Pk-50)
LAVENDER Cap EDTA K2, 4mL, 13x75 (Pk-50)
GOLD Cap Serum Clot Act Gel Sep 5mL 13x100 (Pk-50)
Tourniquet Latex-Free (Pk-25)
Needles
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)
Needle Holder
Adult Needle Holder- single use T (Pk-10)
Containers/Kits
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 (Each)
Myco/Ureaplasma collection swab (Each)
Pinworm Collection Bottle (Each)
Copan Stool Collection Device C/S (Each)
Stool O&P Bottle (Each)
Stool O/B (Each)
Swab Clear Amies (general culture) (Bag-50)
Swab Chlamydia (STI) (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)
Patient Instruction Sheets
24 Hour Urine sheet (Each)
Fungus Instruction Sheet (Each)
Pinworm Sheet (Each)
Semen Analysis Sheet (Each)
Sputum C&S Sheet (Each)
Stool O&P Sheet (Each)
Preview PDF
Submit
PARTNER SUPPLY REQUISITION - Dynacare
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