Supply Order Form FAX TO (209) 577-1725 CALL (209) 577-1200 ext. 295 Date* Client Name* Client Account Number* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code REQUISITION / FORMSCytology/GYN (PAP’s) Prostate Histology/Non-GYN Cytology Gastroenterology Custom Print Requisitions Supply Order Forms SUPPLIESProstate Kits – 6 Bottles Prostate Kits – 12 Bottles Prostate Kits – Cassettes Formalin Bottles (7 ml) Formalin Bottles (20 ml) Formalin Bottles (40 ml) Formalin Bottles (60 ml) Formalin Bottles (90 ml) Formalin Bottles (120 ml) SurePath™ Vials 25 per SurePath™ vial & accessories (broom or brush*) 25 per ThinPrep® 25 per ThinPrep ® vial & accessories (broom or brush*) 25 per Spirabrush CX ® ECC Brush Cervex-Brush Combi Aptima ® Vaginal Swab CytoLyt Solution 30 ml Tube CytoLyt Solution 30 ml Cup CytoLyt Fixative 4 oz. Spray Bottle Hematopathology Kit/Bone Marrow Kit Slides (100 pack) Urine cups (4.5 oz. sterile) Fish Kit (Bladder Kits) Michel’s Transport 8 oz. Containers Fill Type Prefilled Empty 16 oz. Containers Fill Type Prefilled Empty 32 oz. Containers Fill Type Prefilled Empty 64 oz. Containers Fill Type Prefilled Empty 92 oz. Containers Fill Type Prefilled Empty 165 oz. Containers Fill Type Prefilled Empty Specimen Bags – Small Specimen Bags – Large Specimen Lock Box * Please specify broom or brush accessories Other (Please specify)PLEASE ALLOW 3 DAYS FOR DELIVERYSupply form completed by: CAPTCHA
