Supply Order Form

Supply Request

All approved supply requests are processed within 24 hours and are shipped via UPS Ground service. If an expedited delivery is required, please let us know in the comments section.
Your Information

We will reach out to you with any questions.
Your Name

First NameLast Name
Email
A confirmation email and tracking information will be sent to this email address.
Phone Number
Format: (000) 000-0000.
Shipping Information

The supplies will be delivered using the information provided below.
Requesting Facility
Attention:
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code

Supplies Needed
- Urine Collection Supplies
- Requisition Quantity
- Prefill facility information?
- Facility Name
  Name of facility for pre-printed requisitions
- Urine Cups w/ Vacutainer Lids
  Includes temp strip
- Urine Tubes (No additive)
  Includes temp strip
- Toilet Hats
- Specimen Bags
- UPS Bags and Return Labels
- UPS Shipping Boxes
- Other Supplies
- Small Gloves Box
  Each box contains 100 gloves (50 pairs)
- Medium Gloves Box
  Each box contains 100 gloves (50 pairs)
- Large Gloves Box
  Each box contains 100 gloves (50 pairs)
- X-Large Gloves Box
  Each box contains 100 gloves (50 pairs)
- Label Printer Rolls
- Other (Please Specify)
  Be as specific as possible. Vague requests can delay shipments if verification is needed.
- Additional Information
  Let us know of any additional needs or requests associated with this supply request.
- IMPORTANT: Federal and State Law mandates that Clinical Laboratories may only provide clients with supplies directly related to the collection of specimens for the laboratory and in amounts proportionate to specimens received from the client.
- Should be Empty: