Supply Order Form NOTE: Orders submitted by 2:00PM EST will be processed the following business day and shipped via UPS Ground. Normal delivery time is 2-3 business days. Rush requests MUST be made in the special instructions box below.
Practice Name
*
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requester Name
*
Requestor Email
Respiratory Pathogen/COVID Testing Supplies
COVID/RPP Kits # Requested (each)
COVID/RPP Requisition Forms (Quantity Desired)
Toxicology Testing Supplies
Toxicology Requisition Forms (Enter Quantity Desired)
Urine Specimen Cups w/Temp Strip (Pack of 100 cups) Enter # of packs
Tox Oral Swabs (Enter Quantity Desired)
POC Cups (Order directly from supplier, fee applies)
Please send POC Order Form
AIM UTI Testing Supplies
AIM UTI Requisition Form (Enter Qty Desired)
UTI Collection Kits (Includes Cup, Two Collection Tubes, BZK Wipe, Biobag)
PGx and CGx Testing Supplies
PGx/CGx Requisition Forms (Enter Quantity Desired)
Buccal Swabs (For PGx and CGx Collection. Enter Qty Desired)
Wound Care Testing Supplies
Wound Care Swabs (Qty of 50 per pack; 1 Per Patient) Enter # of Packs
Wound Care Reqs Enter Qty Desired
Shipping Supplies and Biohazard Bags
Biohazard Bags (Qty of 50 per pack) Enter # of Packs
UPS Shipping Boxes (Qty of 20 per pack) Enter # of packs
UPS Labpaks (Enter Quantity Desired)
UPS Shipping Labels (Enter Quantity Desired)
For Practices With Care Coordinators ONLY
Printer Ink Needed-Please send model and type of printer.
Yes
No
Dymo Labels
Yes
No
Special Requests/Instructions
Submit
Should be Empty: