Outreach Clinic Supply Order Form

Reference laboratory supply order requisition

Client name

Email address

Street address

City

Ordered by

Date

General supplies

Enter the quantities in the fields below.

Biohazard bags (each)

Formalin bottles, small

Formalin bottles, large

Needles 21G

Needles 22G

Self-adhesive wrap (Coban)

Thin Prep PAP and brushes

Tourniquets (each)

Tubes, Autosep-SST

Tubes, 2.7 mL Blue top sodium citrate

Tubes, Green top sodium heparin

Tubes, Green top lithium heparin

Tubes, Plain red top

Tubes, 3 mL EDTA purple top

Tubes, 6 mL EDTA pink top (blood bank)

Tubes, 2 mL gray top sodium fluoride/potassium oxalate

Urine container, routine (random)

Urine container, clean catch

Vacutainer Holders

Microbiology supplies

Enter the quantities in the fields below.

Aptima device – cervical

Aptima device – urine

Bacterial culturettes (E swabs)

Blood culture bottle, anaerobic, orange

Blood culture bottle, aerobic, green

M4 Viral Transport Media (Viral studies)

Para-Pak stool collection set

Royal blue – EDTA

Royal blue – no additives

Specimen collection container (Hats)

Transport tubes

Urine culture tubes, 4mL gray top

Forms

Enter the quantities in the fields below.

Anatomic Pathology forms

Cytology tickets

Roll of labels

Supply Order forms

Testing Requisition form

Miscellaneous

Add miscellaneous items and quantiles below.

Type here

Outreach Clinic Supply Order Form

Reference laboratory supply order requisition

General supplies

Microbiology supplies

Forms

Miscellaneous

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