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#NP48TX0-1RPlease enter a number greater than or equal to 0.Needle Eclipse, Green, 21G (48 Each) REF#368607Please enter a number greater than or equal to 0.Needle Eclipse, Black, 22G (48 Each) REF#368608Please enter a number greater than or equal to 0.Butterflies Safety-Lok 21G (50 Each) REF#367281Please enter a number greater than or equal to 0.Butterflies Safety-Lok 23G (50 Each) REF#367297Please enter a number greater than or equal to 0.Butterflies Safety-Lok 25G (50 Each) REF#367285Please enter a number greater than or equal to 0.McKesson Bandages 1" X 3" (100 Each) REF#16-4811Please enter a number greater than or equal to 0.Monoject Luer Adapter (100 Each) REF#881225257Please enter a number greater than or equal to 0.Vacutainer Needle Holders - Hubs (250 Each) REF#364815Please enter a number greater than or equal to 0.Collection Blood TubesTiger Top SST Tubes 8.5ml (100 Each) REF#367988Please enter a number greater than or equal to 0.Gold Top SST Blood Collection 5ml (100 Each) REF#367986Please enter a number greater than or equal to 0.Gold Top SST Blood Collection 4ml (100 Each) REF#367977Please enter a number greater than or equal to 0.Grey Top Blood Sodium Fluoride Potassium Oxalate 4ml (100 Each) REF#367922Please enter a number greater than or equal to 0.Grey Top Blood Sodium Fluoride Potassium Oxalate 2ml (100 Each) REF#367921Please enter a number greater than or equal to 0.Red Top Blood Collection 5ml (100 Each) REF#367814Please enter a number greater than or equal to 0.Red Top Blood Collection 10ml (100 Each) REF#367820Please enter a number greater than or equal to 0.Clear & Red Top No Additive (Z) 6ml (100 Each) REF#366408Please enter a number greater than or equal to 0.PST Gel & Lithium Hep Light Green (Mint) Top 3ml (100 Each) REF#367960Please enter a number greater than or equal to 0.Dark Green Blood Collect Lithium Heparin 6ml (100 Each) REF#367886Please enter a number greater than or equal to 0.Dark Green Blood Collect Sodium Heparin (NH) 6ml (100 Each) REF#367878Please enter a number greater than or equal to 0.Dark Royal Blue Top Trace Element Serum 6ml (100 Each) REF#368380Please enter a number greater than or equal to 0.Dark Royal Blue Top Trace Element K2 EDTA 6ml (100 Each) REF#368381Please enter a number greater than or equal to 0.KS Medical Lavender Tops K2 EDTA 4ml (100 Each) REF#367861Please enter a number greater than or equal to 0.Light Blue Top Blood Collection Buffered Sodium Citrate (9 NC) 2.7ml (100 Each) REF#363083Please enter a number greater than or equal to 0.BD Microtainer Lavender K2 EDTA (50 Each) REF#365974Please enter a number greater than or equal to 0.Specimen Transport4x6 Specimen Routine Bag (100 Each) REF#1P46B3TPlease enter a number greater than or equal to 0.6x9 Specimen Routine Bag (100 Each) REF#1P69BASPlease enter a number greater than or equal to 0.6x9 Specimen STAT Bag (200 Each) REF#Q603Please enter a number greater than or equal to 0.12x15 Specimen Bags X-Large (100 Each) REF#Q606Please enter a number greater than or equal to 0.6x9 Frozen Specimen Bag (100 Each) REF#1P69BBLPlease enter a number greater than or equal to 0.McKesson Pippettes Non-Sterile(500 Each) REF#559Please enter a number greater than or equal to 0.Plastic Transfer Vial 5ml (100 Each)Please enter a number greater than or equal to 0.Vial transfer Amber Light Protected (100 Each)Please enter a number greater than or equal to 0.BD Microtainer SST Amber Microyard (50 Each) REF#365978Please enter a number greater than or equal to 0.Collection Urine24HR Urine Container w/ HCL (1 Each) REF#21584Please enter a number greater than or equal to 0.24HR Urine Container Plain (1 Each) REF#DYND80024Please enter a number greater than or equal to 0.Urine Collection Kit (Grey top, Urine Transfer Straw) (50 Each) REF#364953Please enter a number greater than or equal to 0.C&S Preservative Urine Tube (Grey Top) 100 Each REF#364951Please enter a number greater than or equal to 0.Urine Analysis Preservative Tube (Yellow & Red Top) 100 Each REF#364992Please enter a number greater than or equal to 0.Urinalysis Urine Tube (Yellow Top) 100 Each REF#364979Please enter a number greater than or equal to 0.Urine Collection Cup 90 ml (100 Each) REF#137169Please enter a number greater than or equal to 0.Collection StooliFOBT Mailer (25 per box) REF#CM25Please enter a number greater than or equal to 0.Stool Culture (C&S) (20 per box) REF#900612Please enter a number greater than or equal to 0.Stool Clean Vial (20 per box) REF#900312Please enter a number greater than or equal to 0.Para-Pak (ZnPVA) (10 per box) REF#301012Please enter a number greater than or equal to 0.Fecal Fat Container (1 Each) REF#3192Please enter a number greater than or equal to 0.Collection MicrobiologyCulture Swab (50 per bag) REF#149712Please enter a number greater than or equal to 0.COPAN FLOQSwabs (100 per box) REF#553CPlease enter a number greater than or equal to 0.NTM/AFB Take Home Kit, Sputum (Specimen container, shipping supplies) (1 Each)Please enter a number greater than or equal to 0.Aptima Urine Kit (Ct/Ng) (50 Each) REF#301040Please enter a number greater than or equal to 0.Orange Aptima Multitest Swab (50 Each) REF#PRD-03546Please enter a number greater than or equal to 0.Aptima Unisex Kit (Ct-Conjunctival) (50 Each) REF#301041Please enter a number greater than or equal to 0.UTM Media Tubes (Red Top) 50 EA REF#3C075NPlease enter a number greater than or equal to 0.EDF 903 Blood Spot Card 5 Spot (100 Per Pack) REF#10550021REVAAPlease enter a number greater than or equal to 0.EZ-Quant Pediatric (Medtox) Lead Test w/2 Spot Card (1 Per Bag) REF#107973Please enter a number greater than or equal to 0.Miscellaneous SuppliesGTT Beverage 75 GM (6 Each) REF#401526FBPlease enter a number greater than or equal to 0.GTT Beverage 50 GM (6 Each) REF#401272PPlease enter a number greater than or equal to 0.Blue Specimen Log Sheets (100 Per Pack) REF#137581Please enter a number greater than or equal to 0.Collection Cytology / HistologyFormalin 20ml Prefilled Container (25 per box)Please enter a number greater than or equal to 0.Formalin 40ml Prefilled Container (25 per box)Please enter a number greater than or equal to 0.Formalin 60ml Prefilled Container (25 per box)Please enter a number greater than or equal to 0.Formalin 120ml Prefilled Container (25 per box)Please enter a number greater than or equal to 0.Thinprep Vial (25 Each)Please enter a number greater than or equal to 0.Other:Please list any other supplies and their quantities.
