Clinic and shipping information
Clinic name
*
Account #
*
Ordered by
*
Order date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Ship to address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supplies requested (For items sold by the dozen, enter the number of dozens}
prev
next
( X )
Submission forms (no charge)
Free
$
Free
Quantity
Mini Tip Culturettes (per dozen)
Free
$
Free
Quantity
Regular Tip Culturettes (per dozen) (no charge)
Free
$
Free
Quantity
Anaerobic Culturettes (per dozen)
Free
$
Free
Quantity
Serum Transport Tubes (no charge)
Free
$
Free
Quantity
Green Top Separator Tubes (per dozen)
Free
$
Free
Quantity
Hematocrit Tubes, larger, heparinized / red banded (no charge)
Free
$
Free
Quantity
Glass Coverslips (no charge)
Free
$
Free
Quantity
Fecal Trichrome Tubes, green bullets with safe fixative (no charge)
Free
$
Free
Quantity
Sample Bags, zip-top (no charge)
Free
$
Free
Quantity
Plastic Slide Boxes (no charge)
Free
$
Free
Quantity
Calorad (16 oz bottle)
Free
$
Free
Quantity
Agrisept (1 oz bottle)
Free
$
Free
Quantity
FedEx Clinical Packs, outer shipping overwrap with government info (no charge)
Free
$
Free
Quantity
Notes
Please verify that you are human
*
Submit
Should be Empty: