Cunningham Pathology - Supply Request Form

Full Name: *

First Name Last Name

E-mail: *

Practice Name: *

Requesting Physician: *

Phone Number: *

Shipping Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

20 ML, 10% Buffered Formalin

(24 per pkg, 96 per case) (Size used mostly for Derm specimens)

Quantity: *

40 ML, 10% Buffered Formalin

(24 per pkg, 96 per case) (Size used mostly by OBGYN)

Quantity: *

60 ML, 10% Buffered Formalin

(24 per pkg, 96 per case)

Quantity: *

90 ML, 10% Buffered Formalin

(24 per pkg, 96 per case)

Quantity: *

120 ML, 10% Buffered Formalin

(4 oz, 24 per pkg, 96 per case)

Quantity: *

240 ML, 10% Buffered Formalin

(8 oz, 24 per pkg)

Quantity: *

360 ML, 10% Buffered Formalin

(12 oz, 24 per pkg)

Quantity: *

480 ML, 10% Buffered Formalin

(16 oz, 24 per pkg)

Quantity: *

1000 ML, 10% Buffered Formalin

(32 oz, 4 per case) (Placenta)

Quantity: *

3840 ML, 10% Buffered Formalin

(128 oz, 4 per case) (Placenta or Breast Reduction)

Quantity: *

Bone Marrow Kits

(Each)

Quantity: *

Michel's Fixative Solution

(Each)

Quantity: *

95% Isopropyl (Bronchial) Note: Preservecyt Solution may be used for most procedures

(Each)

Quantity: *

4 oz Empty Containers Sterile

(Each)

Quantity: *

8 oz Empty Containers Non-Sterile

(Case of 100)

Quantity: *

16 oz Empty Containers Non-Sterile

(Case of 100)

Quantity: *

32 oz Empty Containers Non-Sterile

(Case of 100)

Quantity: *

64 oz Empty Containers Non-Sterile

(Case of 50)

Quantity: *

86 oz Empty Containers Non-Sterile

(Case of 25)

Quantity: *

128 oz Empty Containers Non-Sterile

(Case of 25)

Quantity: *

172 oz Empty Containers (Placenta & Breast Reduction) Non-Sterile

(Case of 10)

Quantity: *

6x9 Biohazard Transport Bags

(Pkg. of 100) (Case of 1000)

Quantity: *

Large Plastic Biohazard Transport Bags

(500 per case) (Indicate Number Desired)

Quantity: *

Thin Prep Pap Test Brushes or Spatulas

(250 per Box) (Flat of 25)

Quantity: *

Thin Prep Pap Test Cervical Papette Brooms

(250 per Box) (Flat of 25)

Quantity: *

Preservcyt Solution 2 oz Vial (Bronchial and/or urine procedures)

(50 per Case) (Flat of 25)

Quantity: *

ABN Forms (Advanced Beneficiary Notice)

(Each)

Quantity: *

Soft Biopsy Brushes

(Each)

Quantity: *

Pap Link Cards

(Each)

Quantity: *

BD Affirm VPIII

(Box of 10)

Quantity: *

One Swab Collection for Multiple Tests

(Each)

Quantity: *

Gen-Probe Aptima Unisex Swab Specimen Collection Kit (Purple)

(Each)

Quantity: *

Gen-Probe Aptima Unisex Swab Specimen Collection Kit (Yellow)

(Each)

Quantity: *

Soft ECC Brushes

(Each)

Quantity: *

Standard / Histology / Cytology Requisition Form

(Each)

Quantity: *

Dermatopathology Requisition Form

(Each)

Quantity: *

Hematopathology Requisition Form

(Each)

Quantity: *

GYN Cytology / Molecular Requisition Form

(Each)

Quantity: *

Additional Notes: