Pathology Laboratory - Supply Request Form

Personal Information
Contact Name:*

First NameLast Name
Today's Date:*

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Office Name:*
Shipping Address:*

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Practice Name:*
Phone:*

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What Type of Supplies Do You Need?*

HistologyCytologyMolecularForms & Transport BagsSpecial Requests
Histology
40ml - Biopsy jars, prefilled formalin

96/Case (Click to Select Quantity)
Quantity:*
40ml - Biopsy jars, prefilled formalin

24/Box (Click to Select Quantity)
Quantity:*
60ml - Biopsy jars, prefilled formalin

96/Case (Click to Select Quantity)
Quantity:*
60ml - Biopsy jars, prefilled formalin

24/Box (Click to Select Quantity)
Quantity:*
1 qt - Biopsy buckets, small

Each (Click to Select Quantity)
Quantity:*
1/2 gal - Biopsy buckets, medium

Each (Click to Select Quantity)
Quantity:*
1 gal. - Biopsy buckets, large

Each (Click to Select Quantity)
Quantity:*
40ml - Specimen jar, empty

Each (Click to Select Quantity)
Quantity:*
Prostate biopsy kit - 12 part

Each (Click to Select Quantity))
Quantity:*
Michel's media (vial for immunofluorescence)

Each (Click to Select Quantity)
Quantity:*
Formalin, bulk

Each (Click to Select Quantity)
Quantity:*
Biopsy Container Labels

30/Sheet (Click to Select Quantity)
Quantity:*
Soft-ECC - $3.75

Each (Click to Select Quantity)
Quantity:*
Soft-Biopsy - $3.75

Each (Click to Select Quantity)
Quantity:*
Cytology
ThinPrep kits - w/brush & scraper

25/pkg (Click to Select Quantity)250/Case (Click to Select Quantity)
Quantity*
ThinPrep kits - w/Cervex broom

25/pkg (Click to Select Quantity)250/Case (Click to Select Quantity)
Quantity*
CytoLyt - 120ml fixative jars

Each (Click to Select Quantity)
Quantity*
UroVysion FISH kits

Each (Click to Select Quantity)
Quantity*
FNA kits

Each (Click to Select Quantity)
Quantity*
Slide mailers, plastic 2-slide

Each (Click to Select Quantity)
Quantity*
Microscope slides

72/Box (Click to Select Quantity)
Quantity*
ARC (Anal-rectal Cytology) kits

Each (Click to Select Quantity)
Quantity*
Molecular
Sterile Urine Cup (120ml), Empty

Each (Click to Select Quantity)
Quantity*
BD Affirm VPIII transport kits

10/Box (Click to Select Quantity)
Quantity*
Buccal Swab for CF testing

Each (Click to Select Quantity)
Quantity*
APTIMA Vaginal Swab STT (ORANGE)

Each (Click to Select Quantity)
Quantity*
APTIMA Urine STT (YELLOW)

Each (Click to Select Quantity)
Quantity*
Group B Strep Tubes for Prenatal Testing

Each (Click to Select Quantity)
Quantity*
Culture Tube (Blue Top)

Each (Click to Select Quantity)
Quantity*
Color Genomics BRCA 1 & 2 Kit

Each (Click to Select Quantity)
Quantity*
Forms & Transport Bags
Requisition forms

75/pkg (Click to Select Quantity)
Quantity*
Medicare ABN forms

Each (Click to Select Quantity)
Quantity*
Supply order forms

Each (Click to Select Quantity)
Quantity*
Bio-hazard transport bags, 6"x9"

100/pkg (Click to Select Quantity)
Quantity*
Multi-specimen bags, 12"x15" (CLEAR)

Each (Click to Select Quantity)
Quantity*
Patient Billing Notice Pads

50/Pad (Click to Select Quantity)
Quantity*
Hand Warmers (Lockboxes - Extreme Cold)

2/Pkg (Click to Select Quantity)
Quantity*
Special Requests
Additional Notes:*
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Personal Information

Histology

Cytology

Molecular

Forms & Transport Bags

Special Requests