Arizona Dermatopathology - Supply Request Form (New)

Supply Order Form
Requestor

First NameLast Name
Practice Name*
Practice Operating Hours*
Please indicate what time your office will be closed (include lunch hours if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Available Supplies- Please check the box of items you would like to order:
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Small Specimen Jars (Box of 24)
20mL 10% Neutral Buffered Formalin filled container

$ Free Quantity



Medium Specimen Jars (Box of 24)
40mL 10% Neutral Buffered Formalin filled container

$ Free Quantity



Large Specimen Jars (Box of 24)
60mL 10% Neutral Buffered Formalin filled container

$ Free Quantity



Extra Large Specimen Jars (Box of 24)
90mL 10% Neutral Buffered Formalin filled container

$ Free Quantity



Large Empty Specimen Containers (each)
Large containers for large specimens - no formalin included in container

$ Free Quantity



Michel's Solution (each)
7mL container of Michel's Solution for DIF specimen transport

$ Free Quantity



Small Specimen Bags (100 pack)
6x9in zip-closure specimen bags

$ Free Quantity



Large Specimen Bags (50 pack)
15x17in extra large bags

$ Free Quantity



LaserJet Label Paper (250 pages)
Paper for printing electronic requisitions with peel-off labels

$ Free Quantity



Requisition Forms (each)
Pre-printed Dermatopathology Requisition forms with carbon copy and 6 peel-off label stickers for specimen containers

$ Free Quantity



Specimen Logs
Specimen logs with double carbon copy sheets for tracking specimens sent to the lab

$ Free Quantity



Printer Ink Cartridge
Please indicate ink cartridge number in the comments section (ex. 206A), for lab-supplied printers only

$ Free Quantity



Specimen Labels
Printable labels for DYMO or other label printing software

$ Free Quantity



FedEx Supplies
Please specify what is needed in the comments section (ex. Small box, clinical pak, airbills, etc)

$ Free Quantity



Total

$0.00
Preferred Delivery Date

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Date
Comments
Please include any order comments or item specifications here
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Supply Order Form