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Order Lab Supplies
Order Lab Supplies
mkulwiec
2019-09-18T07:05:33-04:00
Lab Supply Order Form
Account Information: *(required)
Site / Account Number
Physician Name
*
Address
*
City
*
State
*
Zip
*
Phone Number
*
Email address
*
Specimen Packing Supplies:
Biohazard Medium Bag – 6 x 9 inch (Pack of 50)
0
1
2
3
4
PACK(S)
Dry Keratin Specimen Bag (Pack of 50)
0
1
2
3
4
PACK(S)
Empty Specimen Transport Box – 2 Vial
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Empty Specimen Transport Box – 6 Vial
0
1
2
3
4
5
6
7
8
9
10
20 mL Vials – EMPTY (pack of 25)
0
1
2
3
4
60 mL Sterile Vials – EMPTY (each)
0
1
2
3
4
5
6
7
8
9
10
Formalin Vials - 20 mL (Pack of 24)
0
1
2
3
4
Formalin Vials - 60 mL (Pack of 24)
0
1
2
3
4
Collection / Transport Kit – 2 Vial
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Includes 2 20 mL formalin containers, dry keratin bag, 6 x 6 biohazard bag.
Collection / Transport Kit – 6 Vial
0
1
2
3
4
5
6
7
8
9
10
Includes 6 20 mL formalin containers, dry keratin bag, 6 x 6 biohazard bag.
Collection / Transport Kit – 1 Vial (90 mL)
0
1
2
3
4
5
6
7
8
9
10
Includes one(1) 90 mL formalin container with formalin.
Collection / Transport Kit – 1 Vial (180 mL)
0
1
2
3
4
5
6
7
8
9
10
Includes one(1) 180 mL formalin container with formalin.
Collection / Transport Kit – 1 Vial (500 mL)
0
1
2
3
4
5
6
7
8
9
10
Includes one(1) 500 mL formalin container with formalin.
Epidermal Nerve Fiber Density Testing Kit – Single Biopsy Location
0
1
2
3
4
5
6
7
8
9
10
ENFD kits are sent with prepaid FedEx Clinical Paks and Airbills unless indicated in the Comments section below.
Epidermal Nerve Fiber Density Testing Kit – Dual Biopsy Locations
0
1
2
3
4
5
6
7
8
9
10
Aspiration Biopsy Kit – ETOH / Dehydrated Alcohol – 2 Vial
0
1
2
3
4
5
6
7
8
9
10
eSwabs (pack of 2)
Nail Unit / Keratin Analysis Kit
Contains 5 USPS Prepaid Mailers, 5 Dry Keratin Requisitions, 5 Dry Keratin Biohazard Bags.
Specimen Transport Supplies:
FedEx Clinical Pak (mailing bag)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EACH
FedEx Prepaid Airbills
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EACH
UPS Clinical Pak (mailing bag)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EACH
UPS Prepaid Airbills
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
EACH
United States Postal Service Prepaid Dry Keratin Mailer
USPS Mailers are to be used for routine dry keratin specimens.
Forms
Podiatry Requisition Form
0
10
25
50
100
Dry Keratin Requisition Form
0
10
25
50
100
ENFD Requisition Form
0
10
25
50
100
Surgery Center & Family Practice Requisition Form
0
10
25
50
100
Supply Order Forms
Specimen Vial Labels (28 per sheet)
Patient Information Materials
Skin Cancers of the Feet Brochure (English)
Skin Cancers of the Feet Brochure (Spanish)
Mini Skin Cancer Poster (English)
Mini Skin Cancer Poster (Spanish)
Additional Comments or Instructions
Confirm your information is accurate
