CLM Home Page CLM Overview Medical Staff Professional Staff Physician Resources Overview Laboratory Portals Lab Medicine Updates Consult Request Form • Supplies Request Privacy Practices Patient Draw Sites Laboratory Medicine Consultation Program Transfusion Medicine Consultative Services Laboratory Partner Community Service Pathology Education Consortium
	Consultants in Laboratory Medicine : Supplies Request   Instructions: Fill out your practice information, date, and person placing the order. Complete the form by entering numbers into the QUANTITY field for the supplies you are requesting. Click the PRINT button. YOU MUST PRINT THE FORM IN LANDSCAPE MODE. Fax the printed form to ProMedica Laboratories at 419-479-6099. Practice Name:   Date: 7/30/2010 Address: Ordered By: City, State, Zip: Remember Info: (Practice Info Only) Phone Number:   ITEM # DESCRIPTION UNIT OF ISSUE QUANTITY   BLOOD DRAWING SUPPLIES BLUE 1.8 mL Each 355157 BLUE 2.7 mL 100/Pack 336172 BLUE 4.5 mL 100/Pack GRAY 3 mL Each 355164 GREEN w/ black ring 4 mL 50/Pack 335153 GREEN MICROTAINER 600 uL Pack 355154 LAVENDAR 4 mL 50/Pack 355153 PINK Hemogard 6 mL 100/Pack 335208 LAV MICROTAINER 500 uL Pack 02-688-70 NAVY w/green label (Na Heparin) 7 mL Each 02-688-72 NAVY w/red label (no additive) 7 mL Each 355167 SST RED w/yellow ring 4 mL 50/Pack 355161 RED TOP w/black ring 4 mL 50/Pack 355159 RED TOP 10 mL 100/Pack 335154 SST MICROTAINER 600 uL Pack 355163 WHITE (waste) Tube 4 mL 50/Pack 02-684-26 YELLOW ACD Sol A 7 mL Each 02-684-29 YELLOW ACD Sol B 7 mL Each 174356 SYRINGE 3 mL Box 174372 SYRINGE 6 mL Box 174204 SYRINGE 12 mL Box 174202 SYRINGE 20 mL Box 174321 VACU NEEDLE 21 x 1 Box 174320 VACU NEEDLE 21 x 1 1/2 Box 186500 SAFETY VACU HOLDER 25/Bag 175295 Safety Straight Needles/Female Adapters 21 x 1 25/Pkg 175296 Safety Straight Needles/Female Adapters 22 x 1 25/Pkg 175297 Safety Straight Needles/Female Adapters 23 x 1 25/Pkg 144446 TOURNIQUETS Each   BLOOD CULTURE BOTTLES 4402260 AEROBIC BLOOD CULTURE BOTTLES Each 4402191 ANAEROBIC BLOOD CULTURE BOTTLES Each 4402194 PEDIATRIC BLOOD CULTURE BOTTLES Each   TRANSPORT BAGS 715003 REGULAR SPECIMEN BAGS Pack 715004 STAT SPECIMEN BAGS Pack 715005 LARGE SPECIMEN BAGS Pack   SPECIMEN TRANSPORT SYSTEMS 154128 STERILE SPECIMEN CUPS 20/Box 715289 ANTISEPTIC TOWELETTES 100/Box 145142 U-BAG PEDIATRIC Each 144426 U-BAG NEWBORN Each 154120 24HR URINE (NO ADDITIVE) Each 144051 SPECIPAN (HAT) Each M4BSRT M4RT (Viral Swab) Each 392073 PARA-PAK (O&P) Each 23290147 STOOL C&S Each L4321606 PORT A CUL (for anaerobic cultures) 10/Box SK61100 HEMOCCULT SLIDES Each 14-959-65B PINWORM COLLECTION Each 1490569 TRANSITUBE DUALSWAB (BBL/CoPan/Fisher) 50/Pack M8508-1A TRANSITUBE MINITIP (BBL/CoPan/Fisher) Each   CYTOLOGY/PATHOLOGY Digene Cervical Samplers Each 575A-15 FORMALIN JARS  15mL of formalin in 30ml jar Each 575A-40 FORMALIN JARS  40mL of formalin in 60mL jar Each 575A-90 FORMALIN JARS  90mL of formalin in 120mL jar Each MILEX CERVICAL SCRAPER (WHITE) 25/Pack 990320 PAP KITS (slide, holder, brush, scraper) 25/box Each THIN PREP BOTTLES 25/Tray THIN PREP BRUSHES 25/Pack THIN PREP SCRAPERS 25/Pack THIN PREP BROOMS 25/Pack   FORMS TH-5335 Advance Beneficiary Notice (ABN) Each TH-5229 Genetic Triple Screen Brochures (purple) Each TH-5359 Genetic Triple Screen Forms Each HIV Consent Forms Each ProMedica Clinical Requisitions 100/Stack ProMedica Dermatology Requisitions 100/Stack ProMedica/CLM Pathology Requisitions 100/Stack
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