Client name: [ClientName]

Email address: [EmailAddress]

Street address: [StreetAddress]

City: [City]

Ordered by: [OrderedBy]

Date: [Date]

[Biohazardbags] Biohazard bags (each)

[Formalinbottlessmall] Formalin bottles, small

[Formalinbottleslarge] Formalin bottles, large

[Needles21G] Needles 21G

[Needles22G] Needles 22G

[SelfAdhesiveWrapCoban] Self-adhesive wrap (Coban)

[ThinPrepPAPandbrushes] Thin Prep PAP and brushes

[Tourniquets] Tourniquets (each)

[TubesAutosepSST] Tubes, Autosep-SST

[Tubes2-7mLBluetopsodiumcitrate] Tubes, 2.7 mL Blue top sodium citrate

[TubesGreentopsodiumheparin] Tubes, Green top sodium heparin

[TubesGreentoplithiumheparin] Tubes, Green top lithium heparin

[TubesPlainredtop] Tubes, Plain red top

[Tubes3mLEDTApurpletop] Tubes, 3 mL EDTA purple top

[Tubes6mLEDTApinktopbloodbank] Tubes, 6 mL EDTA pink top (blood bank)

[Tubes2mLgraytop] Tubes, 2 mL gray top sodium fluoride/potassium oxalate

[Urinecontainerroutinerandom] Urine container, routine (random)

[Urinecontainercleancatch] Urine container, clean catch

[VacutainerHolders] Vacutainer Holders

Microbiology Supplies

[Aptimadevicecervical] Aptima device â€“ cervical

[Aptimadeviceurine] Aptima device â€“ urine

[BacterialculturettesEswabs] Bacterial culturettes (E swabs)

[Bloodculturebottleanaerobicorange] Blood culture bottle, anaerobic, orange

[Bloodculturebottleaerobicgreen] Blood culture bottle, aerobic, green

[M4ViralTransportMediaViralStudies] M4 Viral Transport Media (Viral studies)

[Parapakstoolcollectionset] Para-Pak stool collection set

[RoyalblueEDTA] Royal blue â€“ EDTA

[Royalbluenoadditives] Royal blue â€“ no additives

[SpecimenCollectionContainerHats] Specimen collection container (Hats)

[Transporttubes] Transport tubes

[Urineculturetubes4mLgraytop] Urine culture tubes, 4mL gray top

Forms

[AnatomicPathologyforms] Anatomic Pathology forms

[Cytologytickets] Cytology tickets

[RollofLabels] Roll of labels

[SupplyOrderforms] Supply Order forms

[TestingRequisitionform] Testing Requisition form

Miscellaneous

Other items and quantities:

[Multiple-LineText]

Additional information or comments: [AddInfo]

Reference laboratory supply order requisition

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