School Nurse Order Form

School Nurse Order Form

For more information contact:

Deb Willcockson

Center for Advocacy and Outreach

Office:515-241-6728

*You may fax your order to 515-241-6732*

If you are ordering for more than your own building, please contact us.

Dressing Supplies

Quantity / Item /

Qty Sent

2x2 gauze (2/pkg)
4x4 gauze (2/pkg)
Band Aids (Limit 5)
EZ Scrub Brush (sterile surgical scrub brush, Limit 3)
Kling – 2 inch roll (Limit 3)
Kling – 4 inch roll (Limit 3)
Ace Wrap – 2 inch (Limit 3)
Ace Wrap – 3 inch (Limit 3 )
Paper Tape – 1 inch roll (Limit3)
Silk Tape – 1 inch roll (Limit 3)
Transpore – 1 inch roll (Limit 3)
Telfa pad – 3x4 inch (1/pkg)
Eye pads

Airway and Respiratory Supplies

Quantity / Item /

Qty Sent

Child Resuscitation Mask
Pediatric Disposable Ambu Bag / with child mask (Limit 1)
Pediatric Non-Rebreather (for O2 on site only)
Nebulizer Tubing and Pediatric Aerosol Mask(Limit 3)

Gloves (vinyl/non-latex)

Quantity / Item ( 2 BOX LIMIT ) /

Qty Sent

Small
Medium
Large

Miscellaneous supplies

Quantity / Item /

Qty Sent

Plastic Medicine Cups (Limit 2 )
Cotton tipped applicators (2/pkg)
Tongue Depressor
Ice Bags (you fill, Limit 5)
Saline Bullets
Alcohol Prep Pads (Limit 1)
Emesis Basin
Wash Basin

Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital does not warrant the medical supplies and equipment supplied pursuant to this order form for merchantability and fitness for a particular purpose. Furthermore, Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital does not warrant the products to be free from defects and shall not be responsible for any defects in quality and workmanship or inappropriate usage.

______hereby releases Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital, their officers, directors, employees and agents from any and all liability associated with the supply, storage or usage of these products.

Signature ______Title ______Date______

SCHOOL NURSES from POLK, DALLAS and WARREN COUNTIES

We respectfully request that youpick up your orders.

Please contact Deb Willcockson for arrangements to pick up your supplies at our office.

Blank Children’s Hospital – Anna Blank Building

1206 Pleasant Street, Des Moines, IA 50309

Email: ; or by phone 515-241-6728

Savings on shipping allow us to direct more of our funding toward supplies.

The following information is required for all orders:

Email Address ______

Contact Person ______Phone (______)______

Name of School ______

Shipping Address______

City______County______State______Zip ______