Pathology Solutions - Supply Request Form

Name:*

First Name Last Name
Practice Name:*
Delivery Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:*
Date Needed By:*

MonthDay Year
Please select the type of supplies you wish to order (check all that apply):*

Laboratory SuppliesPrinter SuppliesRequisition FormsSpecial Requests
Laboratory Supplies
Prefilled NBF, 7ml

100/case (click to select quantity)
Quantity:*
Prefilled NBF, 20ml

96/case (click to select quantity)
Quantity:*
Prefilled NBF, 40ml

96/case (click to select quantity)
Quantity:*
Prefilled NBF, 60ml

96/case (click to select quantity)
Quantity:*
Ova & Parasite Para-Pac (O+P)

5/case (click to select quantity)
Quantity:*
Stool Transport Para-Pac (Clean)

5/case (click to select quantity)
Quantity:*
Stool Culture Para-Pac (C+S)

5/case (click to select quantity)
Quantity:*
Mucous Specimen Trap, 40ml

25/case (click to select quantity)
Quantity:*
Biopsy Pads (Blue)

1,000/pack (click to select quantity)
Quantity:*
Cytology Cup 50ml - Tall/Skinny Contains 30ml of fluid

25/case (click to select quantity)
Quantity:*
CytoLyt Cup 120ml - Short/Fat Contains 30ml of fluid

50/case (click to select quantity)
Quantity:*
DIF Cup 20ml - Michel's Media

1 each (click to select quantity)
Quantity:*
FNA Cytology Kit

1 each (click to select quantity)
Quantity:*
Prostate Kits (12 vials)

1 each (click to select quantity)
Quantity:*
Prostate Kits (12 vials with cassettes)

1 each (click to select quantity)
Quantity:*
Sterile Urine Cups

100/case (click to select quantity)
Quantity:*
Cytology Brushes - 95% Alcohol

1 each (click to select quantity)
Quantity:*
Biohazard Transport Bags - 6x9

1000/case (click to select quantity)
Quantity:*
Biohazard Transport Bags - 12x15

500/case (click to select quantity)
Quantity:*
Patient Billing Tear-Off Pads

50 sheets/pad (click to select quantity)
Quantity:*
Courier Labels Book

50 sheets/pad (click to select quantity)
Quantity:*
Barrett’s FISH Kit

1 each (click to select quantity)
Quantity:*
Bladder FISH Kit

1 each (click to select quantity)
Quantity:*
Urine Cytology Kit

1 each (click to select quantity)
Quantity:*
Printer Supplies
DYMO Labels 30572 - 260 per roll

2/pack (click to select quantity)
Quantity:*
DYMO Labels 30252 - 350 per roll

2/pack (click to select quantity)
Quantity:*
DYMO Labels 30330 - 500 per roll

1/pack (click to select quantity)
Quantity:*
Requisition Forms
Mod Med Paper

250/pack (click to select quantity)
Quantity:*
General Requisitions

25/pack (click to select quantity)
Quantity:*
GI Requisitions

25/pack (click to select quantity)
Quantity:*
Urology Requisitions

10/pack (click to select quantity)
Quantity:*
Cytology Requisitions

10/pack (click to select quantity)
Quantity:*
Dermatology Requisitions

25/pack (click to select quantity)
Quantity:*
Special Requests
Please state the nature of your request:
Should be Empty:

Laboratory Supplies

Printer Supplies

Requisition Forms

Special Requests