Request Supplies

Supply Order Form

**Please allow 48 hours for all orders to be filled**

To submit your order via courier or fax, please use printable form.

Date of Request (required)

Requesting Office (required)

Person Ordering


PRW Requisition Forms - 100/ per pack

Quantity:

ModMed/EMA paper with labels (pack) - 100/ per pack

Quantity:

ModMed/EMA paper with labels (case) - 1000/ per case

Quantity:

Specimen bags (pack) - 100/ per pack

Quantity:

Labels for bottles (sheet) - 30/ per sheet

Quantity:

Specimen Bottles:

20ml (sm) Formalin Jars - 96/ per case
Quantity:

40ml (lg) Formalin Jars - 96/ per case
Quantity:

60ml (xlg) Formalin Jars - 24/ per box
Quantity:

120ml (2xl) Formalin Jars - 24/ per box
Quantity:

Prostate Kits:

6 core - 1/ per kit
Quantity:
12 core - 1/ per kit
Quantity:

Michel's Fixative vials (immunofluorescence testing)

Quantity:

Culture Swabs - 10/ per pack

Quantity:

DTM vials (Dermatophyte Test Medium) - 20/ per box

Quantity:

Laboratory Info Leaflets (for patients) - 100/ per pack

Quantity:

Specimen Log Forms - 25/ per case

Quantity:

Printer/Copy Paper - 1 case

Quantity:

Printer Ink:

Cartridge #:

Additional Comments/ Requests