Supply Order Form

SUPPLY ORDER FORM

Supplies ordered after 2:00pm EST will ship the following business day (Monday-Friday). All supplies are shipped via FedEx Ground unless otherwise approved.
Facility Name*
Specify location if there are multiple.
Your Name

First NameLast Name
Your E-mail*
You will receive a confirmation email at this address.

Requisitions

Requisitions

	Quantity	Prefilled?
Infectious Disease Requisitions
Gastrointestinal (GI+) Requisitions
PGx+ Requisitions w/ Medical Necessity
Toxicology Requisitions
Clinical Requisitions (Blood)

Pre-filled Requisition Information
Clinic Name & Location (if multiple locations), Address, Phone Number, Ordering Provider - NPI# (if multiple providers need to be listed the last name of each may need to be used instead of the full name)

UTI+ & STI Supplies

UTI+ & STI Collection Devices

	Quantity Requested
Collection Cups and Tubes
Collection Cups
Collection Tubes
Clean Catch Wipes
Adult Brief Swabs (E-swabs)
Urine Straws
6x9 Specimen Bag
Toilet Hats

Wound+ Supplies

Wound+ Collection Devices

	Quantity Requested
Wound+ E-Swab
6x9 Specimen Bag

Nail+ Supplies

Nail+ Collection Devices

	Quantity Requested
Nail+ Collection Bag
6x9 Specimen Bag

RPP+ Supplies

RPP+ Collection Devices

	Quantity Requested
Nasopharyngeal Swab
Oropharyngeal Swab
COVID-19 Saliva Collection
6x9 Specimen Bag

Women's Health+ Supplies

Women's Health+ Collection Devices

	Quantity Requested
Aptima Swabs
Thin Preps
Obstetrical Wipes
6x9 Specimen Bag

PGx+ Supplies

PGx+ Collection Devices

	Quantity Requested
PGx+ Collection Kit (2 swabs per patient)
6x9 Specimen Bag

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

GI+ Supplies

GI+ Collection Devices

	Quantity
Fecal Swab
6x9 Specimen Bag
Gastrointestinal (GI+) Requisitions

Blood Supplies

Blood Collection Tubes

	Quantity
Lavender (K2EDTA Additive) Blood Tube 4mL
Plain (No Additive) Blood Tube 6mL
Green (Sodium Heparin) Blood Tube 6mL
Red/Gray (SST Clot Activator/Separator) 8.5mL
Gold (SST Clot Activator/Separator) 5mL
Light Blue (Sodium Citrate Additive) 3.5mL
Gray (Glucose Sodium Fluoride/na2 EDTA Additive) 2mL
Green( Lithium Heparin Separator Gel Additive) 5mL

Blood Draw Supplies

	Quantity
21 Gauge 1 1/4 Needle
22 Gauge 1 1/4 Needle
23 Gauge 3/4 Butterfly Needle
21 Gauge 3/4 Butterfly Needle
Collection Tube Holder (Hub/Needle Holder)
Tourniquet
Alcohol Prep Pad
5cc Luer Lock Syringe
Cohesive Bandages (Coban)
Gauze Sponge
Medium Cotton Ball
Large Cotton Ball
6x9 Specimen Bag

Critical Level Emergency Contact

In order to perform blood testing for a facility, we must have a critical level emergency contact on file. If you have not submitted this information yet please complete the form here: Critical Level Contact Form
Critical Level Contact Acknowledgement*

I acknowledge that a Critical Level Contact is on file for the facility receiving the supplies.

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

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

CityState

Zip Code
Should be Empty:

SUPPLY ORDER FORM