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 Latex Bag (100 Each)Needle 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#16-4811Transfer Tubes (100 Each)Vacutainer Luer Adapter (100 Each)Vacutainer 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#363083Specimen TransportSpecimen Routine Bag (100 Each)Specimen STAT Bag (200 Each)Specimen Bags X-Large (100 Each)Frozen Specimen Bag (100 Each)Pippettes (100 Each)Plastic Transfer Vial 5ml (1000 Each)Vial transfer Amber Light Protected (100 Each)Red Flange Cap (1000 Each)Collection Urine24HR Urine Container w/ Boric Acid (1 Each)24HR Urine Container w/ HCL (1 Each)24HR Urine Container Plain (1 Each)Urine 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)Collection StooliFOBT Mailer (1 Each)Stool 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)Collection 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) (1 Each) REF#301040Orange Aptima Multitest Swab (1 Each) REF#PRD-03546Aptima Unisex Kit (Ct-Conjunctival) (1 Each) REF#301041UTM Media Tubes (Red Top) 50 EA REF#3C075NMiscellaneous SuppliesGTT Beverage 75 GM (6 Each)GTT Beverage 50 GM (6 Each)Collection 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.
