Cunningham Pathology - Supply Request Form

Full Name:*

First NameLast Name

E-mail:*

Practice Name:*

Requesting Physician:*

Phone Number:*

Format: (000) 000-0000.

Shipping Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

20 ML, 10% Buffered Formalin

(24 per pkg, 96 per case) (Size used mostly for Derm specimens)

Quantity:*

40 ML, 10% Buffered Formalin

(24 per pkg, 96 per case) (Size used mostly by OBGYN)

Quantity:*

60 ML, 10% Buffered Formalin

(24 per pkg, 96 per case)

Quantity:*

90 ML, 10% Buffered Formalin

(24 per pkg, 96 per case)

Quantity:*

120 ML, 10% Buffered Formalin

(4 oz, 24 per pkg, 96 per case)

Quantity:*

240 ML, 10% Buffered Formalin

(8 oz, 24 per pkg)

Quantity:*

360 ML, 10% Buffered Formalin

(12 oz, 24 per pkg)

Quantity:*

480 ML, 10% Buffered Formalin

(16 oz, 24 per pkg)

Quantity:*

1000 ML, 10% Buffered Formalin

(32 oz, 4 per case) (Placenta)

Quantity:*

3840 ML, 10% Buffered Formalin

(128 oz, 4 per case) (Placenta or Breast Reduction)

Quantity:*

Bone Marrow Kits

(Each)

Quantity:*

Michel's Fixative Solution

(Each)

Quantity:*

95% Isopropyl (Bronchial) Note: Preservecyt Solution may be used for most procedures

(Each)

Quantity:*

4 oz Empty Containers Sterile

(Each)

Quantity:*

8 oz Empty Containers Non-Sterile

(Case of 100)

Quantity:*

16 oz Empty Containers Non-Sterile

(Case of 100)

Quantity:*

32 oz Empty Containers Non-Sterile

(Case of 100)

Quantity:*

64 oz Empty Containers Non-Sterile

(Case of 50)

Quantity:*

86 oz Empty Containers Non-Sterile

(Case of 25)

Quantity:*

128 oz Empty Containers Non-Sterile

(Case of 25)

Quantity:*

172 oz Empty Containers (Placenta & Breast Reduction) Non-Sterile

(Case of 10)

Quantity:*

6x9 Biohazard Transport Bags

(Pkg. of 100)(Case of 1000)

Quantity:*

Large Plastic Biohazard Transport Bags

(500 per case)(Indicate Number Desired)

Quantity:*

Thin Prep Pap Test Brushes or Spatulas

(250 per Box)(Flat of 25)

Quantity:*

Thin Prep Pap Test Cervical Papette Brooms

(250 per Box)(Flat of 25)

Quantity:*

Preservcyt Solution 2 oz Vial (Bronchial and/or urine procedures)

(50 per Case)(Flat of 25)

Quantity:*

ABN Forms (Advanced Beneficiary Notice)

(Each)

Quantity:*

Soft Biopsy Brushes

(Each)

Quantity:*

Pap Link Cards

(Each)

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BD Affirm VPIII

(Box of 10)

Quantity:*

One Swab Collection for Multiple Tests

(Each)

Quantity:*

Gen-Probe Aptima Unisex Swab Specimen Collection Kit (Purple)

(Each)

Quantity:*

Gen-Probe Aptima Unisex Swab Specimen Collection Kit (Yellow)

(Each)

Quantity:*

Soft ECC Brushes

(Each)

Quantity:*

Standard / Histology / Cytology Requisition Form

(Each)

Quantity:*

Dermatopathology Requisition Form

(Each)

Quantity:*

Hematopathology Requisition Form

(Each)

Quantity:*

GYN Cytology / Molecular Requisition Form

(Each)

Quantity:*

Additional Notes: