Supply Order Form
1 4 5 1 N O RT H S I D E D R I V E N W | S U I T E A | AT L A N TA , G A 3 0 3 1 8
( t e l ) 4 0 4 . 2 2 8 . 5 0 2 7 | ( f a x ) 4 0 4 . 3 4 3 . 0 0 8 7 | [email protected]
Client Name
C L I A # I I D2 0 6 5 3 I 8 | LABSOLUTIONS.COM
Address
Requested By
Request Date
Date Needed By
Monthly Sample Estimate
PGX:
COMPUTER HARDWARE
m Complete Computer Setup
m Dymo Printer Labels (2 packs)
Phone
Tox:
CC/Hem:
m Laptop
m Printer
m Dymo Printer
m Ethernet Cord
m Copy Paper (1 pack)
m Surge Protector
m Ink Cartridge ________ (type)
m Other _________________
FORMS / REQUISITIONS
m Tox Req
m Molecular Req
_____ x50
_____ x50
m CC/Hem Req
m Patient Auth.
_____ x50
_____ x50
m LNM
m ABN
_____ x50 - [ ] RESPONSETM [ ] DISCOVERTM [ ] PREDICTTM
_____ x50
CLINICAL CHEM / HEMATOLOGY SUPPLIES
m New Clinical Chem/Hematology Account Setup
______ x100/tray
______ x50/pack
m SST (Red/Gray)
m Vacuum Needles
______ x100/tray
______ x100/pack
m Serum (Red)
m Absorbent Mats
______ x100/tray
______ x25/box
m EDTA (Lavender)
m Tourniquets
______ x50/pack
______ x200/box
m Transfer Tubes
m Alcohol Pads
______ x50/pack
______ x100/box
m Transfer Pipettes
m Band-Aids
______ x20/pack
_____ x200/pack
m Butterfly Needles
m Gauze
______ x50/pack
______
m Cotton Balls
m Sharps Container
______
______
m Caddy/Rack
m Test Tube Trays
______
m Biohazardous Bag (Sharps)
m Other _____________________________________________________________________________________________________
COLLECTION DEVICES / POC CUPS
m BD Vacutainer Urine Kit
m 12 Panel POC Cup w/o Bup
m 12 Panel POC Cup w/Bup
m Security Seals
m Buccal Swab: DNA Genotek
_____ x50/order
_____ x25/order ($3.75/cup)
_____ x25/order ($3.75/cup)
_____ x25/order
_____ x25/order
m Saliva Collection
m Oral Fluid Device (Quantisal)
m Specimen Cups
m Temperature Strips
m Buccal Swab: Dry
_____ x25/order
_____ x25/order
_____ x50/order
_____ x50/order
_____ x25/order
CC / HEMATOLOGY EQUIPMENT
m Centrifuge
m Refrigerator
_____
_____
OFFICE SUPPLIES
m Gloves
m Sharpie
_____
m Clipboard
_____
m Copy Paper (1 pack)
_____
_____
SHIPPING SUPPLIES
m Biohazardous Bags
______
m FedEx Clinical Paks
m UPS LabPaks
______
m UPS Preprinted Labels ______ m Specimen Lockbox
______
m UPS Boxes
______
m FedEx Boxes
______
______
______
m FedEx Preprinted Labels ______
m UN3373 Label
m Cool/Ice Packs
______
m Insulated Pack
______
NOTES
PLEASE EMAIL COMPLETED FORMS TO [email protected] or fax to 404.343.0087. All orders MUST be received by
3:00 pm for same day packaging and shipping. Please allow 2 business days for delivery.
Requester’s Signature ___________________________________ Sales Rep / Account Manager (print) __________________________________
Last revised May 3, 2016