Supply Order Form 12/20

Email Sender Name
Used for Submission/Notification Email Purposes
IMPORTANT Federal and State Law mandates that Clinical Laboratories may give clients only those supplies directly related to the collection of specimens and in amounts proportionate to specimens received from the client. Supply orders are processed Monday – Friday from 8:00AM – 3:00PM. Please allow 24 - 36 hours for supply requests to be filled. Specimen Bags are included with all collection kit/device orders: (1) specimen bag per (1) media unit.

Request Information
Facility Name:*
Specify which clinic if the facility has multiple locations.
Request Date:*

MonthDayYear
MM/DD/YYYY
Delivery Location:*

Directly to FacilityEmployee Residence
Delivery Method:*
"Courier (EMERGENCY ONLY)" option applies to Courier-based accounts only; please contact your Territory Manager for more information.
Employee:*
ATTN:
Delivery Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Any additional comments, notes, providers (prefilled requisitions), or requests regarding this Supply Order can be made on the following page under the Additional Information section.

Molecular Testing Supplies
Test-Collection Kits

RPPEENTGIUTISTIWoundWHFungal
Respiratory Pathogen Panel

RPP
Option #1: Dasky Kit*
Quantity | Order as Kit [1 kit = 50 swabs, tubes, bags]
eSwab™ Pack (White Cap)*
Quantity | Order as Each
COVID-19 RT-PCR

COVID-19
Option #1: Dasky Kit*
Quantity | Order as Kit [1 kit = 50 swabs, tubes, bags]
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Eye, Ear, Nose, & Throat Panel

EENT
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Gastrointestinal Panel

GI
FecalSwab® Pack (Orange Cap)*
Quantity | Order as Each
Urinary Tract Infection Panel

UTI
Option #1: UTI/PCR - Flocked Swab Pack*
Quantity | Order as Each
Option #2: UTI/PCR - UA and C&S Tubes w/ Integrated Transfer*
Quantity | Order as Each
Option #3: UTI/PCR - C&S Tube with Integrated Transfer*
Quantity | Order as Each
Option #4: UTI/PCR, UA, and C&S Tube with Integrated Transfer*
Quantity | Order as Each
Sexually Transmitted Infection by PCR

STI
Option #1: STI Kit - Urine*
Quantity | Order as Each
Option #2: eSwab™ Pack (White Cap)*
Quantity | Order as Each
Wound Panel

Wound
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Women's Health Panel with STI

WH w/ STI
eSwab™ Pack (White Cap)*
Quantity | Order as Each
Fungal Panel

Fungal
Translucent Tube & Alcohol Pad*
Quantity | Order as Each

Submission Signature & Additional Information
By signing below, I acknowledge that I have completed this Supply Order Form to the best of my ability and have communicated all details regarding this order with the Supply department via online submission and/or email (if necessary).

Should the recipient not receive the requested supplies within 48 hours, I understand it will be my responsibility to contact the Supply department via email (supplies@coastdiagnostics.com) to alert them of any missing supply items.
I checking 'I Agree', I acknowledge that I have completed this Supply Order Form to the best of my ability and have communicated all details regarding this order with the Supply department via online submission and/or email (if necessary). Should the recipient not receive the requested supplies within 48 hours, I understand it will be my responsibility to contact the Supply department via email (supplies@coastdiagnostics.com) to alert them of any missing supply items.*

I Agree
Requestor Signature:*

Clear
Acknowledgment Signature

To request prefilled requisition forms for additional Providers, the following information is required:

First & Last Name - NPI Number

ex: Dr. John Doe - 0123456789

Please Note: Prefilled requisition forms will not be sent for a Provider if any of their specific information above is missing.

This information can be submitted in the Additional Notes or Comments field below.

Submit
*This form is automatically sent to supplies@coastdiagnostics.com upon submission.
Should be Empty:

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