GPA Laboratories - Supply Request Form

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Office Information
Practice Name:*
Requesting Physician:*
Phone Number:*

Area Code Phone Number
Shipping Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
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FormsBagsContainersCytologyLabelsMiscellaneousOther
Forms
Clinical ABN Pads - English

50/Pad (Click for Quantity)
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AP/Cytology ABN Pads - English

50/Pad (Click for Quantity)
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AP/Cytology ABN Pads - Spanish

50/Pad (Click for Quantity)
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Blank Paper with Labels at Bottom for LifePoint

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Clinical/Cytology Requisitions (White)

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Cytology/Surgical Requisitions (Gold)

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Dermatopathology Requisitions (White)

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GI Requisitions (Green)

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Urology Requisitions (Blue)

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Information Pads for Patients

50/Pad (Click for Quantity)
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Modernizing Medicine Requisition Paper - 6 Labels

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Log Sheets for Tracking Specimen

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Supply Request Forms

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Bags
6x9 Small Bags with Pouch (Clear)

50/Pack (Click for Quantity)
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12x15 Large Opaque Bags

50/Pack (Click for Quantity)
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18x20 Opaque Bags

50/Pack (Click for Quantity)
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Sterile Ziplock Bags for Nail Clippings

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Containers
Containers - 1 Gallon

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Containers - 16oz (No Formalin)

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Containers - 64oz (No Formalin)

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Containers - 165oz (No Formalin)

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Immunofluorescent Transport Media (Michel's)

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Prostate Kits

12 Bottles (Click for Quantity)2 Bottles with Cassettes (Click for Quantity)
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Tissue, Formalin Jars - 7ml

196/Case (Click for Quantity)
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Tissue, Formalin Jars - 20ml

64/Case (Click for Quantity)
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Tissue, Formalin Jars - 40ml

96/Case (Click for Quantity)
Quantity:*
Tissue, Formalin Jars - 60ml

96/Case (Click for Quantity)
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Tissue, Formalin Jars - 120ml (For Leep Bxs)

96/Case (Click for Quantity)
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Tissue, Formalin Jars - 1000ml

96/Case (Click for Quantity)
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Sterile Containers w/ Lid - 120ml

96/Case (Click for Quantity)
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Cytology
BD Affirm Vaginitis Collection Kit

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Gen-Probe Optima CT/NG Swab Collection Kit

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Gen-Probe Optima CT/NG Urine Collection Kit

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Non-GYN Alcohol Slide Holder

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Non-GYN Cytolyt Preservative (FNA's & Fluid)

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Non-GYN Slides and Holders (FNA's & Fluid)

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Non-GYN Spray Fixative for Slides

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Non-GYN Urine Preservcyt

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Surepath Vial with Brush/Spatula

25/Tray (Click for Quantity)
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Surepath Vial with Broom

25/Tray (Click for Quantity)
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Thinprep Vial with Brush/Spatula

25/Tray (Click for Quantity)
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Thinprep Vial with Broom

25/Tray (Click for Quantity)
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Labels
Blank Labels

1/Roll (Click for Quantity)
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Mailing Labels - Express Mail (USPS)

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Mailing Labels - FedEx

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Miscellaneous
Bottle Racks for 7 ml Bottles

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Bottle Racks for 20ml Bottles

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Cork/Pins for Leep Boxes

1/Box (Click for Quantity)
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Directory of Services

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Lockbox/Key - Floor

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Lockbox/Key - Over the Door

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Mailing Boxes - Express Mail (USPS)

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Mailing Boxes - FedEx Mail

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Other
Other Notes:*
Should be Empty:

Office Information

Forms

Bags

Containers

Cytology

Labels

Miscellaneous

Other