Supply Request Form - Pathology Consultants

Supply Request Form

Supplies are delivered to clients only for collection, transport and report of testing sent to Pathology Consultants, PC or Northwest Pathology Services, LLC.

CLIENT NAME

PHONE #

DATE

ADDRESS

ORDERED BY

CYTOLOGY SUPPLIES

PART #

ThinPrep Brooms Only, 25/pk

ThinPrep Brush/Spatula Only, 25/pk

ThinPrep Kit/Vials & Brooms, 25/pk

70101-001 70124-001 70136-002

ThinPrep Kit/Vials & Brushes, 25/pk 70136-001

Dry 5-Slide Shipper

SM500-100

CytoVial

ThinPrep Cytolyt, 120 mL Bottle, 30 mL Fill

MISC. SUPPLIES

CVP-500/100 0236050 PART #

6 x 10 Routine Spec. Bags, 25/pk BGT0609/0510

10 x 13 Routine Spec. Bags, 25/pk BGT1012/0510

20 x 14 Routine Spec. Bags, 25/pk BGT2014/0510

Coated Slides, Box of 72

38002002

Forms-Tissue Requisition, 25/pk

Labels for Pathology Specimen Bottles, 120/pk

Empty 1.25 Gallon, Screw Top Container

Empty Specimen Container, White 2.5 Liter

Empty Specimen Container, White 5 Liter

MM1.25GAL CT3705 CT3706

PKG Pack Pack Pack Pack Each Each Each PKG Pack Pack Pack Box Pack Pack Each Each Each

QTY FORMALIN SUPPLIES 20 mL Bottle, 10 mL Fill, 24/Box

PART # NB0507

40 mL Bottle, 20 mL Fill, 24/Box

NB0115

60 mL Bottle, 30 mL Fill, 24/Box

120 mL Bottle, 60 mL Fill, 24/Box 240 mL Bottle, 120 mL Fill, NBF 10%, 24/Box 500 mL Bottle, 240 mL Fill, 6/Box

1,000 mL Bottle, 500 mL Fill, 4/Box

NB0230 NB0460 NB08120 NB16240 NB32480

QTY

OTHER TRANSPORT MEDIA

Michel's Medium, Diff Transport Fluid, 20 mL Prefilled

RPMI Media

MOLECULAR COLLECTION KITS

Aptima Multitest Swab

Aptima Unisex Swab

PART # MS0507

PART # PRD-03546

301041

Aptima Urine

301040

BD Max

443376

PKG Box Box Box Box Box Box Box PKG Each Each PKG Each Each Each Each

QTY

QTY QTY

CALL OR FAX FOR SUPPLIES:

Phone: 541.222.6949 | Fax: 541.222.6944 Email: clientservices@

Clientservices/Supply Request Form

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