CP Supply Order Form Name(Required) First Last Date(Required) MM slash DD slash YYYY Phone(Required)Clinic / Practice Name:(Required) Address:(Required) 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 Collection BloodTourniquet Non Latex Bag (100 Each) REF#NP48TX0-1RNeedle Eclipse, Green, 21G (48 Each) REF#368607Needle Eclipse, Black, 22G (48 Each) REF#368608Butterflies Safety-Lok 21G (50 Each) REF#367287Butterflies Safety-Lok 23G (50 Each) REF#367297Butterflies Safety-Lok 25G (50 Each) REF#367285McKesson Bandages 1" X 3" (100 Each) REF#16-4811Monoject Luer Adapter (100 Each) REF#881225257Vacutainer Needle Holders - Hubs (250 Each) REF#364815Collection Blood TubesTiger Top SST Tubes 8.5ml (100 Each) REF#367988Gold Top SST Blood Collection 5ml (100 Each) REF#367986Gold Top SST Blood Collection 4ml (100 Each) REF#367977Tan Top K2 EDTA (K2E) 5.4mg Blood Collection 3ml (100 Each) REF#367855Grey Top Blood Sodium Fluoride Potassium Oxalate 4ml (100 Each) REF#367922Grey Top Blood Sodium Fluoride Potassium Oxalate 2ml (100 Each) REF#367921Red Top Blood Collection 5ml (100 Each) REF#367814Red Top Blood Collection 10ml (100 Each) REF#367820Clear & Red Top No Additive (Z) 6ml (100 Each) REF#366408PST Gel & Lithium Hep Light Green (Mint) Top 3ml (100 Each) REF#367960Dark Green Blood Collect Lithium Heparin 6ml (100 Each) REF#367886Dark Green Blood Collect Sodium Heparin (NH) 6ml (100 Each) REF#367878Dark Royal Blue Top Trace Element Serum 6ml (100 Each) REF#368380Dark Royal Blue Top Trace Element K2 EDTA 6ml (100 Each) REF#368381KS Medical Lavender Tops K2 EDTA 4ml (100 Each) REF#367861Light Blue Top Blood Collection Buffered Sodium Citrate (9 NC) 2.7ml (100 Each) REF#363083BD Microtainer Lavender K2 EDTA (50 Each) REF#365974Specimen Transport4x6 Specimen Routine Bag (100 Each) REF#1P46B3T6x9 Specimen Routine Bag (100 Each) REF#1P69BAS6x9 Specimen STAT Bag (200 Each) REF#Q60312x15 Specimen Bags X-Large (100 Each) REF#Q6066x9 Frozen Specimen Bag (100 Each) REF#1P69BBLMcKesson Pippettes Non-Sterile(500 Each) REF#559Plastic Transfer Vial 5ml (100 Each)Vial transfer Amber Light Protected (100 Each)BD Microtainer SST Amber Microyard (50 Each) REF#365978Collection Urine24HR Urine Container w/ HCL (1 Each) REF#2158424HR Urine Container Plain (1 Each) REF#DYND80024Urine Collection Kit (Grey top, Urine Transfer Straw) (50 Each) REF#364953C&S Preservative Urine Tube (Grey Top) 100 Each REF#364951Urine Analysis Preservative Tube (Yellow & Red Top) 100 Each REF#364992Urinalysis Urine Tube (Yellow Top) 100 Each REF#364979Urine Collection Cup 90 ml (100 Each) REF#137169Kidney Stone Analysis Kit (1 Each) REF#306266Collection StooliFOBT Mailer (1 Each) REF#CM25Stool Culture (C&S) (20 per box) REF#900612Stool Clean Vial (20 per box) REF#900312O & P (ZnPVA) (10 per box) REF#301012Fecal Fat Container (1 Each) REF#3192Collection MicrobiologyCulture Swab (50 per bag) REF#149712UTM Viral Swab (100 per bag) REF#97-2012NTM/AFB Take Home Kit, Sputum (Specimen container, shipping supplies) (1 Each)Aptima Urine Kit (Ct/Ng) (50 Each) REF#301040Orange Aptima Multitest Swab (50 Each) REF#PRD-03546Aptima Unisex Kit (Ct-Conjunctival) (50 Each) REF#301041UTM Media Tubes (Red Top) 50 EA REF#3C075NEDF 903 Blood Spot Card 5 Spot (100 Per Pack) REF#10550021REVAAEZ-Quant Pediatric (Medtox) Lead Test w/2 Spot Card (1 Per Bag) REF#107973Miscellaneous SuppliesGTT Beverage 75 GM (6 Each) REF#401526FBGTT Beverage 50 GM (6 Each) REF#401272PBlue Specimen Log Sheets (100 Per Pack) REF#137581Collection Cytology / HistologyFormalin 20ml Prefilled Container (1 Each)Formalin 40ml Prefilled Container (1 Each)Formalin 60ml Prefilled Container (1 Each)Formalin 120ml Prefilled Container (1 Each)Thinprep Vial (25 Each)Kit Urine Cytology (20 Each)Collection Cytology Solution (4 Each)Other:Please list any other supplies and their quantities.
