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THANK YOU FOR YOUR BUSINESS

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Please allow 3-5 business days for the order to be processed and shipped to your facility

CLIENT SUPPLY REQUISITION

Account Number:

Fax your order to: 1-800-458-1932

Account Phone #:

E-mail your order to: NEPHYSSUPP@

Account Name:

Phone your order to: 1-800-631-5250 Option 4

Requested By:

REQUISITIONS

PLEASE PROVIDE REQUISITION NUMBER FOUND ON UPPER RIGHT

HAND CORNER OF REQUISITION

QTY UNITS

DESCRIPTION

CODE

100

REQUISITION # _________________________

100

REQUISITION # _________________________

100

REQUISITION # _________________________

100

REQUISITION # _________________________

100

CLINICAL REQUSITION (0800)

8002

100

WOMEN'S HEALTH REQUISITION (0200)

0202

100

HISTOLOGY/CYTOLOGY REQUISTION (1200)

8

100

LIQUID BASE CYTOLOGY REQUISITION (1300)

3030

100

MATERNAL SERUM REQUISITION

3

100

GENETICS REQUISITION

25

LCM/PRINTER

PLEASE PROVIDE PRINTER MODEL # LOCATED ON FRONT COVER

OF PRINTER FOR TONER REFILLS (IE: HP1200 OR DELL S2500)

QTY UNITS

DESCRIPTION

CODE

EACH MODEL # ______________________

EACH COLOR MODEL #_____________BLACK INK

EACH COLOR MODEL #_____________CYAN INK

EACH COLOR MODEL #____________ YELLOW INK

EACH COLOR MODEL #___________ MAGENTA INK

250/PK LCM REQUISITION PAPER

4500

500/PK 8 ? x 11 PLAIN WHITE PAPER

4600

500/PK 8 ? x 11 BLUE PAPER

1202

500/PK 8 ? x 11 YELLOW PAPER

1201

QTY

UNITS EACH 30/BOX EACH EACH 25/PACK 25/PACK 25/BAG 100/BAG 100/BOX 25/PACK 25/PACK 25/BAG 25/BAG 25/PACK EACH 50/BOX

HISTOLOGY/CYTOLOGY

DESCRIPTION FORMALIN 20 ML FORMALIN 40 ML PRE FILLED FORMALIN 90 ML FORMALIN 480 ML THIN PREP VIALS W/BRUSH & SPATULA THIN PREP VIALS W/BROOMS THIN PREP BROOMS THIN PREP BRUSHES and SPATULAS THIN PREP BRUSHES SURE PATH VIALS W/BRUSH & SPATUALS SURE PATH VIALS W/BROOMS SURE PATH BROOMS SURE PATH BRUSH & SPATUALS PAP SMEAR KIT W/SCRAPPER & BRUSH CYTOLOGY FIXATIVE SPRAY DIGENE HPV DNA KIT

CODE 2784 450 6008 480 1500 7013 995 0712 445 2790 2780 3577 3801 1015 405 275

QTY

UNITS EACH EACH 50/BAG 100/BAG EACH 100/BOX 80/BOX 50/SL 100/BOX 100/CS EACH 50/BOX

URINE COLLECTION

DESCRIPTION 24HR URINE (NO PRESERATIVE) 24HR URINE HCL____BORIC___ACETIC___ STRAW URINE TRANSFER DEVICE URINALYSIS TUBE (RED/YELLOW TOP) STERILE URINE CUP 4 OZ. URINE C&S TUBE (GREY) URINE CYTOLOGY (CYTOLYTE SOLUTION) URINE COLLECTION 8 OZ. PAPER CUP CASTILE WIPES CHAIN OF CUSTODY KITS (SINGLE) CHAIN OF CUSTODY URINE MAILERS CHAIN OF CUSTODY KITS (DOUBLE)

CODE 470

490/495/515 3649 460 465 230 530 455 700 560 575 1075

QTY

UNITS BOX BOX EACH EACH EACH EACH 100/PK 50/PK 100/PK 200/BOX 100/BOX 100/BAG 200/PK 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX 100/BOX EACH 100/BAG 100/PK EACH EACH EACH EACH

SPECIMEN COLLECTION

DESCRIPTION

21G X 1 ? NEEDLES

22G x 1 ? NEEDLES

QUICK RELEASE NEEDLE HOLDER

TOURNIQUET

SMALL SHARP CONTAINER

LARGE SHARP CONTAINER

SMALL SPECIMEN BAGS

LARGE SPECIMEN BAGS

CLIENT INTERFACE SPECIMEN BAGS (EDI)

ALCOHOL SWABS

BAND-AIDS

COTTON BALLS

GAUZE 2 x 2

LAVENDER TOP (EDTA) 4ML ___ 3ML ___

SERUM SEPARATOR 8.5ML ___3.5ML ___

RED TOP (PLAIN) 10ML ___ 3ML ___

LIGHT BLUE (PT) 2.7 ML

PROTEIN PLASMA TUBE (PPT)

YELLOW ACD SOLUTION A 8.5 ML Tube

YELLOW TOP SOLUTION B 6ML _3ML ___

GREEN TOP 10ML ___3ML ___

GRAY TOP

6ML ___4ML ___

LEAD BROWN TOP 3ML

MICROTAINER SST___WHOLE___EDTA____

GREINER TUBE (NMR TEST) 8.5ML

SERUM TRANSFER TUBE WHITE

TRANSFER PIPETTES

FROZEN SPECIMEN TUBE (TRANSPORT)

FROZEN TRANSPAK CONTAINER

AMBER TRANSFER TUBE (SMALL)

AMBER TRANSFER TUBE (LARGE)

CODE 4800 4900 210 220 740 745 645 650 651 680 690 170 695 300/305 285/290 325/330 355 1800 2016 345/350 335/340 310/315 3678 400/785//5973 6060 380 685 390 370 1155 1150

GLUCOSE TOLERANCE BEVERAGES

EACH FRUIT PUNCH 100GM _____ 50GM________

EACH ORANGE

100GM ______50GM________

670/2500 2000/5000

QTY

MICROBIOLOGY COLLECTION

UNITS

DESCRIPTION

50/BAG TRANSPORT MEDIA (GENERAL CULTURES)

EACH VIRAL & CHLAMYDIA TRANS MEDIA (UTMRT)

50/BOX APTIMA KIT SWAB SPECIMEN-PURPLE

50/BOX APTIMA KIT URINE SPECIMEN-YELLOW

EACH NUSWAB - ORANGE

20/BOX PARA PAK (CULTURE & SENSITIVITY)

20/BOX PARA PAK (CLEAN)

1/KIT

TRANSPORT MEDIA PARA PACK W/FORM

10/BOX AFFRIM VP III TRANSPORT (VAGINOISIS)

EACH BREATH TEST FOR H.PYLORI

EACH STOOL CONTAINER MULTIPURPOSE W/LID

EACH FOBT CHECK

EACH PEDIATRIC BLOOD CULTURE KIT

1/KIT

ADULT BLOOD CULTURE KIT

CODE 225 1300 1041 1042 4787 540 550 545 6255 8208 2544 6666 985 9103

Pa g e 1 o f 2

CLIENT SUPPLY REQUISITION Fax your order to: 1-800-458-1932 E-mail your order to: NEPHYSSUPP@ Phone your order to: 1-888-401-0746 Option 3

THANK YOU FOR YOUR BUSINESS Please allow 3-5 business days for the order to be

processed and shipped to your facility

Account Number:

Account Phone #: Account Name: Requested By:

QTY

UNITS EACH EACH EACH EACH EACH 72/PK 50/PK 25/ROLL 25/ROLL 25/ROLL 25/ROLL 25/ROLL 25/ROLL EACH

MISCELLANEOUS ITEMS

DESCRIPTION SPECIMEN BOX SPECIMEN BOX (OVER DOOR) CENTRIFUGE DIRECTORY OF SERVICE ABN FORM FROSTED SLIDES CARDBOARD SLIDE HOLDER KEEP FROZEN STICKERS LABEL "DO NOT REFRIGERATE" LABEL "PEDIATRIC SPECIMEN" LABEL "STAT " LABEL "PATIENT ID" LABEL "REMOTE OE" SPECIMEN LOG BOOK

CODE 840 850 8550 2001 6016 425 435 585 590 845 595 580 6020 37

ADDITIONAL ITEMS NEEDED:

QTY

DESCRIPTION

Pa g e 2 o f 2

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