Supply Order Form

Supply Order Form
Facility Name/Client ID*
Your Name/Nurse's Name*

First NameLast Name
Your Email*
example@example.com

Requisitions

Requisition's

	Quantity
Physician Office Requisition
Women Health Requisition
Long Term Care Requisition
Toxicology Requisition

Blood Supplies

Blood Collection Tubes

	QTY
EDTA (LAVENDER)
SST (GOLD TOP or RED/YELLOW TOP)
SST (TIGER TOP)
SODIUM CITRATE (LIGHT BLUE TOP)
LITHIUM HEPARIN (GREEN TOP)
SODIUM HEPARIN (GREEN TOP)
NO ADDITIVE OR GEL BARRIER (RED TOP)
NMR LIPO TUBE (BLACK/YELLOW TOP)
QUANTIFERON, GOLD PLUS KIT, 4 TUBE
ACD A (YELLOW)
MATERNI-T (BLK/TAN), Each
EDTA METAL FREE (ROYAL BLUE TOP)

Blood Transfer Tube

	QTY
PLAIN ALIQUOT TUBES/CAPS
FROZEN ALIQUOT TUBES/CAPS (PURPLE)
AMBER TRANSFER TUBE
PIPETTE, TRANSFER
METAL FREE ALIQUOT TUBES/CAPS
PLASMA LABELS
CITRATE PLASMA LABELS
SERUM LABELS
FROZEN SPECIMEN LABELS

Blood Draw Supplies

	QTY
21 GUAGE X 1 1/4 STRAIGHT NEEDLE
22 GUAGE X 1 1/4 STRAIGHT NEEDLE
21 GUAGE 3/4 BUTTERFLY
23 GUAGE 3/4 BUTTERFLY
NEEDLE HOLDER/HUB
TOURNIQUET
ALCOHOL PREP PAD
BANDAIDS
COHESIVE BANDAGES (COBAN)
GUAZE 2X2
SHARPS CONTAINER (1 GAL)
SHARPS CONTAINER (2 GAL)
SHARPS CONTAINER (1 QT)
SYRINGES (5ML)
SYRINGES (10ML)

Additional Items

Collection Containers

Miscellaneous Collection Supplies

	QTY
STERILE CUPS
STERILE CUPS W/ TEMP STRIP
STERILE CUP W/NEEDLE
YELLOW URINE TUBE (TOXICOLOGY)
STOOL C&S CONTAINER (ORANGE)
STOOL OVA & PARASITE (PINK/GREY)
24 HOUR URINE CONTAINER (PLAIN)
24 HOUR URINE CONTAINER (METAL FREE)
24 HOUR URINE CONTAINER (HCL)
E-SWAB (WHITE CAP)
APTIMA URINE TUBE (YELLOW)
PBS SWAB (COVID, RPP, RSV, FLU)
BREATH TEK/UBT (H-PYLORI)
BBL DOUBLE SWAB, LIQUID AMIES (BLUE)
SPUTUM COLLECTION KIT
BLOOD CULTURE KIT
URINE CULTURE KIT
SCABIES KIT
SPECIEMN PAN/HAT

Additional Items

Cytology/Tissue/Obgyn

Cytology Supplies

	QTY
THINPREP VIAL+ BRUSH/SPATULA
THINPREP VIAL+BROOM
THIN PREP BROOM
THIN PREP BURSH/SPATULA
GTT, BEVERAGE, ORANGE 50 GM
GTT, BEVERAGE, FRUIT PUNCH 50 GM
GTT, BEVERAGE, ORANGE 75 GM
GTT, BEVERAGE, FRUIT PUNCH 75 GM
FORMALIN CONTAINER 20ml
FORMALIN CONTAINER 40ml
APTIMA SWAB (ORANGE)

Additional Items

Specimen Transport Supplies

Transport Supplies

	QTY
SPECIMEN BAGS (6"X9")
SPECIMEN BAGS W/ PAD (6"X9")
FROZEN SPECIMEN BAGS (YELLOW)
LARGE SPECIMEN BAGS (12"X15")
XXL SPECIMEN BAGS (21"X18")
FEDEX SHIPPING BAGS
UPS SHIPPING BAGS
FEDEX SHIPPING LABELS
UPS SHIPPING LABELS

Additional Supplies Request
Please provide detailed information: