OGPMSS Requisition for Medical Supplies
Ministry of Health
and Long-Term Care
Ministry Use Only
Ontario Government Pharmaceutical
and Medical Supply Service
Tel. 416 327-0837
Fax 416 327-0818
Order Number
Instructions
• Complete the “ Ship to” information and the “Quantity ordered” column in its entirety.
• Fax your order to OGPMSS at 416 327-0818.
Note: Please refer to the transport schedule for order deadlines to meet the next scheduled delivery for your zone.
Ship to Address
Client Name
Unit No.
Client No.
Street No.
Telephone No.
Street Name
City
Province
Date ordered (yyyy/mm/dd)
Quantity Ordered
(units)
Cups
6530-1950-1
6530-1902-1
6530-1951-0
6530-1952-0
6530-1954-0
Diagnostic Agents
6536-0838-0
Dressings
6510-2228-0
Gloves
6515-2068-0
6515-2067-0
6515-2066-0
6515-2065-0
6515-1913-0
6515-1914-0
6515-1915-0
Sharps Collectors
7240-0019-0
7240-0021-0
7240-0018-1
7240-0018-0
Syringes/Needles
6515-2063-0
Personal Care
6510-1913-2
8520-0017-0
8520-0018-0
6502-1504-2
6576-1706-1
8530-1904-0
8105-0070-0
8105-0080-0
8530-1907-0
8520-1901-5
6529-2006-2
Trays
6515-1950-2
6510-2301-0
Forms
7530-5039-E
X
X
X
X
X
Fax No.
Requisitioner Signature
Ordered By
Authorized Person's Signature
Authorized Person's Name (please print)
Product No.
Postal Code
Units
Carton/1000
Carton/5000
Carton/5000
Carton/5000
Carton/5000
X Bottle/100 strips
Description
Cold drink, paper, waxed/poly-coated, Leak-proof, 5 oz.
Medicine, plastic, graduated, 30mL
Portion, paper, pleated, 15mL
Portion, paper, pleated, 30mL
Portion, paper, pleated, 96mL
Chemstrip 5 (urine strip)
X
Package/50
X
Box/100
Box/100
Box/100
Box/100
Box/100
Box/100
Box/100
Nitrile, powder free, X-Large
Nitrile, powder free, Large
Nitrile, powder free, Medium
Nitrile, powder free, Small
Vinyl, examination, pre-powdered, Large
Vinyl, examination, pre-powdered, Medium
Vinyl, examination, pre-powdered, Small
X
Each/1
Each/1
Each/1
Each/1
Sharps collector 1 litre
Sharps collector 3 litre (Nestable)
Sharps collector 7.6 litre (Nestable)
Sharps collector 10.3 litre
X
Box/100
Safety-engineered Insulin Pen Needle, 29g x 8mm or 30g x 8mm size
X
Package/200
Bottle/114mL
Bottle/540mL
Case/36
Bottle/237mL
Box/250
Case/30 boxes
Case/48 rolls
Package/100
Case/24
Bag/76
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Case/16
Case/20
Wound, transparent, adhesive film, sterile, 10cm x 12cm
Alcohol swabs, Isopropyl Alcohol 70%
Hand sanitizer, ethyl alcohol
Hand sanitizer, ethyl alcohol
Mouthwash alcohol free 115mL
Sun protective lotion SPF 60
Swabstick (for oral care)
Tissue, facial, disposable, white, 2 ply, 21cm x 22.5cm
Tissue, toilet, white, 2 ply, 10.5cm x 11cm
Toothbrush, adult
Toothpaste, fluoride, 18 ml tube
Washcloth, disposable, white 31.25cm x 25cm
Catheterization Tray, disposable
Dressing Tray, disposable 5 item
OGPMSS Requisition for Medical Supplies (Form No. 4495-97E). Form available online at
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/ (form#4495-97E)
Other
X
X
X
Print Form
4495-97E (2016/07)
© Queen's Printer for Ontario, 2016
Disponible en français
Clear Form
7530-5039-E