Labcorp Supply Ordering Form

Client Information

Today's Date Account Name Client Number Order Submitted By Email Phone Number Ship To Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR OT PA RI SC SD TN TX UT VA VT WA WI WV WY ZIP Code

Blood Collection

In the fields below please indicate the number of units you would like to order

ACD Tube Blue Top 4.5 ml Pink Top 6 ml Purple Top Molecular Tube 6 ml Dark Blue No Add Dark Blue EDTA Tan Green with Yellow Ring Lithium Heparin 3 ml Dark Green Sodium Heparin 6 ml Dark Green Lithium Heparin 4 ml Pearl Top 6 ml Lavender Top 4 ml Grey Top 4 ml Serum Separation Tube 5 ml Clear Discard Tube Red Top Tubes Quantiferon Kit Alcohol Pads Safety 21 x 1.25 Safety 22 x 1.25 Vacutainer Holders Glucola 50 gm Glucola 100 gm Bandaids Butterfly 23 g 3/4 Gauze Pads Plastic Serum Trans Tubes with White Cap Tourniquet (non-latex)

Urine Collection

In the fields below please indicate the number of units you would like to order

24 hr Collection Container Antiseptic Towelettes Plastic Urine Transfer Tubes (yellow cap) UA Preservative Tubes and Straws (yellow/red cap) Pippettes Sterile Urine Cup Disposable Urine Dipcups Disposable Urine Dipcups with Lid Urine Collection Hats Urine Culture Kit (with C & S Preservative) (gray top)

Microbiology and Virology

In the fields below please indicate the number of units you would like to order

Aerobic Culture Swabs (Wound, Throat, Strep Screen) Anaerobic Culture Swabs (Deep Wound, Abscess) Blood Culture Bottle - Aerobic Blood Culture Bottle - Anaerobic Blood Culture Bottle - Ped Viral Transport Media (VTM) for Viral/Herpes/Mycoplasma Viral Transport Media (VTM) for Ureaplasma Culture Cobas PCR Container for GC/CT/TRICH - Urine Cobas PCR Container for GC/CT/TRICH - Endocervical Ova and Parasite/Amoeba Collection Kit Stool Culture Collection Kit Affirm Test Kit FOBT Collection Vial FOBT Patient Collection Mailers with Vial Breathtek Kit Flu Swab BD Max UVE Kit - Vaginal Pathogens

Cytology Histology

In the fields below please indicate the number of units you would like to order

Biopsy Containers 40 ml Biopsy Containers 60 ml Biopsy Containers 120 ml Cytology Slides Pap Smear Kit 1-Slide Thin Prep Vials Includes Spatula/Brush Slide Holders (cardboard mailers) Cytology Collection Jar (FNA) Fetal Fibronectin (FFN)

Forms

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AFP (Alpha Feta-Protein) Questionnaire Cytology and Histology Requisitions Drawing Stations Locations/Map Laboratory Requisitions Laser Report Paper Allergen Forms Test Add-On Forms Supply Order Forms - max 5 ABN Forms DYMO Labels GTT Patient Brochure Courier Requisitions

Other

In the fields below please indicate the number of units you would like to order

Large Drop Box Small Drop Box 2300d Printer Toner 2420 Printer Toner 3005 Printer Toner 3015 Printer Toner 64A Printer Toner 6340 Printer Toner 6350 Printer Toner 6360 Printer Toner Photoconductors 6340 Photoconductors 6350 Photoconductors 6360 Critical Frozen - blue slips Molecular Path Slips - yellow Red 8 QT Sharps Container White 3 Gal Sharps Container White Specimen Bags Orange Specimen Bags Green Specimen Bags Blue Specimen Bags Stat Specimen Bags Purple Specimen Bags Large Yellow Plastic Bags