Supply Request Form
Hi there! If you notice something running low, please feel free to submit a request through this form, and management will take care of the rest. We appreciate your help in keeping everything stocked and running smoothly. Thank you so much!
Date of Request
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@qssmed.onmicrosoft.com
Location?
*
Please Select
Irving
Plano
Arlington
Fort Worth
Lake Highlands
Allen
Who is this for?
*
Employees
Patients
Medical Supplies Request
General Supplies: Feel free to search or select Categories
Categories:
All
All
Procedure Day/Patient Supplies
Clinic Lobby Supplies
Snacks
Beverages
Dairy Products
Breakroom Supplies
Cleaning Supplies
Office Supplies
Medications
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Procedure Day/Patient Supplies
White Wristbands
Procedure Day
$
Free
Yellow Wristbands
Procedure Day
$
Free
White Bags
Procedure Day
$
Free
Juice Variety Pack
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Juice Variety Pack - REDUCED SUGAR
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
8oz Water Bottles
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Oreos & Chips Ahoy Variety Pack
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Veggie Straws
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Pretzels
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Liquid IV
TMS
$
Free
16oz Water Bottles
TMS
$
Free
Baby Wipes
Shockwave
$
Free
No RR snacks/beverages need to be replenished
$
Free
Clinic Lobby Supplies
Hot Cups w/ Lids + Sleeves
$
Free
Hot Cups
$
Free
Dum Dum Original Pops
For patients only
$
Free
Starbucks Blonde Roast K-Cup Coffee Pods, Veranda Blend
$
Free
Donut Shop Medium Roast K-Cup Coffee Pods
$
Free
Quantity
Hot Cocoa K-Cup Pods
$
Free
Coffee Creamer Singles
$
Free
Snacks
belVita Bites Breakfast Biscuits
$
Free
Veggie Straws
$
Free
Frito-Lay Baked Variety Pack Chips
$
Free
SkinnyPop Variety Snack Pack Popcorn
$
Free
Veggie Straws
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Pirate's Booty Aged White Cheddar Puffs
$
Free
Chex Mix Traditional Savory Snack Mix
$
Free
Nutri-Grain Bars
$
Free
Special K Pastry Crisps
$
Free
Oreos & Chips Ahoy Variety Pack
Recovery Room
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
KIND Minis Variety Pack
$
Free
Fruit Snacks
$
Free
Nature's Garden Trail Mix Snack Packs
$
Free
Nature's Garden Probiotic Immune Booster Trail Mix
$
Free
Peanut Butter Filled Pretzels
$
Free
Clementine Mandarins
$
Free
Bananas
$
Free
Slim Jim
$
Free
Beverages
Green Tea
$
Free
Starbucks Blonde Roast K-Cup Coffee Pods, Veranda Blend
$
Free
Donut Shop Medium Roast K-Cup Coffee Pods
$
Free
Quantity
Hot Cocoa K-Cup Pods
$
Free
Hot Cocoa Packets w/ Marshmallow
$
Free
Lemon Ginger Herbal Tea
$
Free
Dairy Products
Vanilla Creamer
$
Free
Hazelnut Creamer
$
Free
Almond Milk
Enter description
$
Free
Soy Milk
$
Free
Lactaid 2% Milk
$
Free
Oat Milk
$
Free
Breakroom Supplies
Paper Towels
$
Free
Aluminum Foil
$
Free
Straws
$
Free
Big Paper Plates
$
Free
Small Paper Plates
$
Free
Dish Soap
$
Free
Hand Warmers
$
Free
Cleaning Supplies
33-Gallon Trash Bags
$
Free
13-Gallon Trash Bags
$
Free
Can Liners
$
Free
Lint Roller
$
Free
Compressed Air Dust Cleaner
$
Free
Lysol Disinfectant Spray
$
Free
Glass Cleaner
$
Free
Pine-Sol
$
Free
Dish Soap
$
Free
Hand Soap
$
Free
Fabric Spray
$
Free
Febreze Plug In Air Freshener Refills
Amazon
$
Free
Small Space Air Freshener
$
Free
Mop Head Replacements
$
Free
Toilet Wand Refills
$
Free
Toilet Paper
$
Free
Hand Sanitizer (Pump)
$
Free
Hand Sanitizer Refills
$
Free
Office Supplies
Scotch Tape
$
Free
Packaging Tape
$
Free
Double Sided Tape
$
Free
AA Batteries
$
Free
AAA Batteries
$
Free
C Batteries
$
Free
D Batteries
$
Free
HP Printer Ink - Black
$
Free
HP Printer Ink - Magenta
$
Free
HP Printer Ink - Cyan
$
Free
HP Printer Ink - Yellow
$
Free
Printer Paper
$
Free
Thermal Laminator Paper
$
Free
Label Maker Refill
$
Free
Kleenex Tissues
$
Free
Note Pads
$
Free
Sticky Notes
$
Free
Apple Pencil Tips
$
Free
Pens
$
Free
Pencils
$
Free
Highlighters
$
Free
Sharpies
$
Free
Staples
$
Free
Box Cutters
$
Free
Scissors
$
Free
Medications
Emergen-C Vitamin C
$
Free
Tylenol
Extra Strength
$
Free
Claritin
$
Free
Cough Drops
$
Free
Aleve
$
Free
Can't find what you're looking for? Let us know!
Feel free to leave a link if needed!
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