CLIENT SUPPLY ORDER FORM

Warde Medical

Laboratory

(800) 760-9969

Client Name:

Client No.: Phone No.:

Date Requested: Date Needed:

Ordered By:

For Warde use only

Filled By:______Date:______Time: ______08/05/15

CLIENT SUPPLY ORDER FORM

QTY REQSTD / UNIT / DESCRIPTION / QTY REQSTD / UNIT / DESCRIPTION
TUBES / MICROBIOLOGY/VIROLOGY
ea / 364606 ACD Solution A Yellow / 50/box / Aptima Collection Kits – Gen Probe (purple)
ea / 364816 ACD Solution B Yellow / 50/box / Aptima Urine Collection Kits-Gen Probe (Yellow)
ea / 368380 Dark Blue No Additive / ea / Bordetella-Pertussis media (3 tubes/2 weeks)
ea / 307022 Dark Blue EDTA / 20/box / Chlamydia DFA Kits
ea / 367925 Gray 7 mL (Sodium Fluoride) / 50/box / HPV Collection Kit–Female
ea / 367871 Green tubes 4 mL Na Heparin / ea / M-4 Media RT
ea / 366480 Green 10 mL Na Heparin / ea / Mycoplasma/Ureaplasma Media (UTM)
ea / 367863 Lavender 6 mL / 20/box / Ova & Parasite Kits (2 boxes/week)
ea / 367988 SST 8.5 mL / ea / Quantiferon TB Gold kit
ea / 364960 Yellow/Micro (AFB) (SPS) / BAGS
50/bag / Amber Plastic Vials/Caps / 100/pk / 8 x 10 Sample Specimen –Room Temperature
ea / Blood Serotonin Tubes / 100/pk / 8 x 10 Sample Specimen -Refrigerate
ea / Pyruvate/Lactate Tubes - (3 tubes/2 weeks) / 100/pk / 8 x 10 Sample Specimen -Frozen
1000/bag / Serum Transport Tubes/Caps / 100/pk / 13 x 15 Zip Lock TRANSPORT -Room Temp
1000/bag / Orange caps / 100/pk / 13 x 15 Zip Lock TRANSPORT -Refrigerate
ea / Protease Inhibitor Tube / 100/pk / 13 x 15 Zip Lock TRANSPORT -Frozen
ea / Salivary cortisol tubes / 400/cs / Sample Transport Boxes
ea / SPL metal-free serum tubes / 100/pk / Absorbent shipping pads
ea / 366430 Red-top serum tubes, 10 mL / PRINTER SUPPLIES
TISSUE TRANSPORT MEDIA / ea / Toner cartridge (please include Model #)
ea / Flow Cytometry-MEM / rolls / Zebra Barcode Labels (5000/roll)
ea / Tissue Transport Media –(5 tubes/2 weeks) / ea / Printer Ribbon (please include model #)
ea / URINE CONTAINERS / PAPER, FORMS, & BROCHURES
50/box / 24 Hour Urine Bottles / ea / Requisitions, Test (1000/box)
50/bag / Urine Cups/Green Cap / ea / Chain of Custody Requisitions (FT) (500/box)
100/bag / Urine Cups/Yellow Cap / ea / Warde Catalog
100/bag / Sterile Urine Cups/Orange Cap / 25 pkg / Cystic Fibrosis Brochure English/Spanish
100/box / Chain of Custody Kits (FT) / 25 pkg / Serum Integrated Test English/Spanish
ea / 24 hr urine bottles – acid washed / 25 pkg / Quad Test English/Spanish
ea / Blue cap urine tubes – acid washed / 25 pkg / Full Integrated Test Brochure English/Spanish
MISCELLANEOUS / 25 pkg / First Trimester Scrn Brochure English/Spanish
50/bag / Boric Acid Tablets (1 gram each) / 25 pkg / Sequential Screen Brochure English/Spanish
ea / Stool Containers / ea / Prenatal Information Sheets
ea / NMP22 Kits / ea / Autopsy Chain of Custody requisitions
ea / UroVysion Kits (5 kits/week) / ea / Panorama patient brochure
ea / Stone Risk Kits
ea / Panoroma kits

For Warde use only

Filled By:______Date:______Time: ______08/05/15

CLIENT SUPPLY ORDER FORM

Filled By:______Date:______10/03