SUPPLY ORDER FORM
Supplies ordered after 3:00pm EST will ship the following day. All supplies are shipped via FedEx Ground unless otherwise approved.
Facility Name
*
Specify location if there are multiple.
Your Name
First Name
Last Name
Your E-mail
*
You will receive a confirmation email at this address.
Requisitions
Requisitions
Quantity
Prefilled?
Infectious Disease Requisitions
Yes
No
PGx+ Requisitions w/ Medical Necessity
Yes
No
Toxicology Requisitions
Yes
No
Pre-filled Requisition Information
UTI+ Supplies
UTI+ Collection Devices
Quantity Requested
UTI+ Collection Cups and Tubes
10
20
30
40
50
Other (Put in comments)
UTI+ Collection Cups
10
20
30
40
50
Other (Put in comments)
UTI+ Collection Tubes
10
20
30
40
50
Other (Put in comments)
UTI+ Clean Catch Wipes
10
20
30
40
50
Other (Put in comments)
UTI+ Adult Brief Swabs (E-swabs)
10
20
30
40
50
Other (Put in comments)
UTI+ Urine Straws
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
Toilet Hats
10
20
30
40
50
Other (Put in comments)
Wound+ Supplies
Wound+ Collection Devices
Quantity Requested
Wound+ E-Swab
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
Nail+ Supplies
Nail+ Collection Devices
Quantity Requested
Nail+ Collection Bag
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
RPP+ Supplies
RPP+ Collection Devices
Quantity Requested
Nasopharyngeal Swab
10
20
30
40
50
Other (Put in comments)
Oropharyngeal Swab
10
20
30
40
50
Other (Put in comments)
COVID-19 Saliva Collection
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
Women's Health+ Supplies
Women's Health+ Collection Devices
Quantity Requested
Aptima Swabs
10
20
30
40
50
Other (Put in comments)
Thin Preps
10
20
30
40
50
Other (Put in comments)
Obstetrical Wipes
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
PGx+ Supplies
PGx+ Collection Devices
Quantity Requested
PGx+ Collection Kit (2 swabs per patient)
10
20
30
40
50
Other (Put in comments)
6x9 Specimen Bag
10
20
30
40
50
Other (Put in comments)
TOX+ Supplies
TOX+ Collection Devices
Quantity
Tox+ Cups w/ Vacutainer Tubes
Tox+ Vacutainer Tubes Only
Tox+ Cups w/ Regular Lid
Tox+ Quantisal Saliva Kit
Toilet Hats
Urine Straws
6x9 Specimen Bag
Shipping Supplies
FedEx Supplies
Quantity
FedEx Bags
FedEx Boxes
FedEx Return Labels
Exempt Human Specimen Stickers
UPS Supplies
Quantity
UPS Bags
UPS Boxes
UPS Return Labels
Exempt Human Specimen Stickers
Computer Supplies
Computer Supplies
Quantity
Zebra Printer Labels
Printer Paper (Ream)
Printer Toner
Specify printer model if ordering toner
Other Supplies
Gloves
Size
Quantity (Boxes)
Gloves
Small
Medium
Large
Other (specify)
Other (specify)
Other (specify)
Section Stopper 2
Comments or Additional Supplies
Recipient
*
ALL SUPPLIES ARE SHIPPED VIA FEDEX GROUND UNLESS OTHERWISE APPROVED
Shipping Address
*
Street Address
Street Address Line 2
City
Please Select
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District of Columbia
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Puerto Rico
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South Carolina
South Dakota
Tennessee
Texas
Utah
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Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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