Client Supply Request Form

Please fill in form with your information and list the quantity of the supplies you need. Orders are shipped FedEx 5 day ground. Up to 2 months of supplies may be ordered.

Indicates field is required
Stat Request:	FedEx Number:  STAT requests can be shipped at clients’s expense. STAT requests must be received by 2:00 p.m. MST
Date Requested:
Client Name / Organization:
Client Number:
Contact Person:
Email Address:	format — (test@test.com)
Phone Number:	format — (xxx) xxx-xxxx
Site:
Address:
City:
State:	-- Select -- ALASKA ALABAMA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING
Zip Code:
Quantity Item # Description Quantity Item # Description 10316 Aqui-Pak 6-tube Absorbent Pouch 15650 95kPa Transport Bag 15674 Bio-Pouch Large 95kPa Bag 16532 10 x 10 Biohazard Bag 16660 Micro Swab Transport Shuttle 25/pk 16661 Air Carrier Envelope 14 x 17 in 25/pk 16662 Air Carrier Envelope 19 x 24 in NanoCool 25/pk 21184 8.3ml SPS Tube 100/pk 23687 Box for Medium Canister Kit ( box only) 23409 Box for Large Combo Canister Kit 23765 NAT Kit Box With Logo (box only) 37858 Medium Canister IATA Kit 37861 NAT Transport Kit 38030 Microbial Environmental Monitoring Kit 38078 TBS/Thio Single Shipper System - 8 Tube 38079 TSB/Thio Quad Shipper System - 32 Tube 38088 Nano-CAD IDM/NAT Kit 38090 Nanocool IDM-NAT Micro Combo Kit 38133 LABS Reproductive Kit 38135 Supplemental Swab Kit 38430 LABS International Reproductive Kit 54819 Exempt Human Specimen Label, 500/roll 56400 8 oz. Refrigerant Pack (72/case) 56519 Small EPS Insulated Shipper 56537M Medium EPS Insulated Shipper 56703 Ambient Infectious Shipping System 57185-CS Culture Swab with Aimees Gel (without charcoal) 57208 Gen-Probe Aptima Urine Specimen Collection Kit (50/box) 74802 60 ml Sterile Specimen Container 74865 120 ml Clickseal Container, Sterile BD364606-CS 8.5 ml Yellow Top, ACD (100 per pack) BD366430-CS 10 ml Red Top, No Additive (100 per pack) BD367863-CS 6 ml EDTA (100 per pack) BD367988-CS 8.5 ml Tiger Top, SST (100 per pack) 299749 20 ml TSB (Case-100) 220889 20 ml THIO (Case-100) R05054 PRAS Cooked Meat (Case-100) Lab 4074 Plastic Vials (Serum Transport) Lab SA4044 B Blood Culture Bottles - Aerobic Lab SN4045 R Blood Culture Bottles - Anaerobic 800272-125 Bar Code Labels (2 1/2 W x 1 1/4 L) Micro 800222-075 Bar Code Labels (2 1/4 W x 3/4 L) 38089D T Nano - MTF Donor Kit 15674 9.5kPa Biohazard Specimen transport Bag, Large (Ea.) 16019 6 in x 9 in Biohazard Bag (Ea.) 21732 (D) 4 ml C & S preservative gray top tube for urine testing (100 per pack) (Pk) 38100RD-T DEN-CTS Donor Kit (NanoCool Version) (Ea.) 38102RD-T DEN-Allosource Partner Kit (NanoCool Version) (Ea.) 38129RD-T DEN-Allosource Serology/NAT Testing Kit (Ea.) 38166D-T DEN-MTF ALTLABS Kit (Ea.) 38281D DEN-Mothers Milk Bank Kit (Ea.) 38351RD-T DEN-STAT Organ IDM Kit (Ea.) 38340RD DEN-International Reproductive Kit (Ea.) 38457D DEN-Residual Moisture Shipper Kit (Ea.) 38557D DEN-25 Tube Bulk Shipper Kit (Ea.) 38559D DEN-100 Tube Bulk Shipper Kit (Ea.) 544196 LABS 2-8 Deg. Celsius 48 hrs. Blue Label-NanoCool (100/set) (ST) 544197 LABS 2-25 Deg. Celsius 48 hrs. Red Label Bulk & Foil (100/set) (ST) 544198 LABS 2-8 Deg Celsius 30 hrs. Blue Label-Misc (100/set) (ST) 54607 Biohazard Logo Label (100/set) (ST) 56442 Extra Small EPS Insulated Shipper (Ea.) 57251 (D) Aptima Unisex Swab Specimen Collection Kit (50/cs) (CS) 74868 120ml ClickSeal or Pack Container (Ea.) 74986 4ml Urine C&S Kit (50 per pack) (PK) 20459 Standard Needle/Vacutainer Holder, Single 20465 21g Eclipse Blood Collection Needle 39160D LABS/California Cryobank Kit 39224RD LABS Region 5 OPO Kit (EA) 38512RD STAT Ordgan IDM Kit: Multi-Labs: DEN-STL (NanoCool Version) (Ea.) 39076D LABS Sero MMB Kit   PHILADELPHIA ITEMS 10316G Aqui-Pak 6-tube absorbent pouch (Ea.) 16532G 10x10 Biohazard Bag (Ea.) 16660G Microbiology Swab transport Shuttle with 12x12 inch bag (25/pack) (PK) 16662G Air Carrier Envelope 10 x24 inch (25/pack) (PK) 23409G (P) Large IATA Box (box only) (Ea.) 38030GP PHI-Microbial Environmental Monitoring Kit (Ea.) 38074GP PHI-CTS Donor Kit (non-NanoCool Version) (Ea.) 38088GP PHI-Nano-CAD IDM/NAT Kit (Ea.) 38089GP PHI-Nano-MTF Donor Kit (Ea.) 38102GP PHI-Allosource Partner Kit (NanoCool Version) (Ea.) 38166GP-T PHI-MTF ALTLABS Kit (Ea.) 38351GP PHI-STAT Organ IDM Kit (Ea.) 54607 Biohazard Logo Label (100/set) (ST) 54819G Exempt Human Specimen Label (500/roll) (RL) 56519G Small EPS Insulated Shipper (Ea.) 56537G Medium EPS Insulated Shipper BD364606-CS (P) 8.5ml Yellow Top, ACD (100per pack) (PK) BD367820-CS (P) 10ml Red Top, Serum Tube (Silicone Coated), [plastic (100 per pack) (PK) BD367863-CS (P) 6ml Lavender Top EDTA, plastic (100 per pack) (PK) BD367988-CS (P) 8.5ml Tiger Top, SST (100 per pack) (PK)   ST. LOUIS ITEMS 10316 Aqui-Pak 6-tube absorbent pouch (EA) 16532 10x10 Biohazard Bag (EA) 16660 Microbiology Swab Transport Shuttle with 12x12 inch bag (25/pack) (PK) 16662 Air Carrier Envelope, 19x24inch (25/pack) (PK) 37858S STL-Medium Canister IATA Kit, Refub. (EA) 38030S STL-Microbial Environmental Monitoring Kit (EA) 38102RS-T STL-Allosource Partner Kit (NanoCool Version) (EA) 38116S-T STL-Allosource Partner Kit (non NanoCool) (EA) 38129RS-T STL-Allosource Serology/NAT Testing Kit (EA) 38351RS STL-STAT Organ IDM Kit (EA) 38455RS STL-STAT Organ IDM Kit: Multi-LABS (NanoCool Version) (EA) 38570RS STL-LABS STAT Organ IDM/HLA Kit (NanoCool Version) (EA) 54607 Biohazard Logo Label (100/set) (ST) 54819 Exempt Human Specimen Label, 500/roll (RL) 56519 Small EPS Insulated Shipper (EA) BD264606-CS (S) 8.5ml Yellow Top, ACD (100 per pack) (PK) BD367820-CS (S) 10ml Red Top, Serum Tube (Silicone Coated), [plastic (100 per pack) (PK) BD367863-CS (S) 6ml Lavender Top EDTA, plastic (100 per pack) (PK)
Quantity Item # Manufacture Manufacture Part # Description Alternate Name UOM 4321283 BD 221283 TSA PPM Open Air Plate PK/10 292396 BD 292396 TSA Deep Fill TSA Heavy Fill PK/10 4322248 BD 222248 TSA Rodac Touch Plate PK/10 4321180 BD 221180 SDA Deep Fill SabDex PK/10 4322244 BD 222244 SDA Rodac Sabdex Rodac PK/10 364992 BD 364992 Urine Tubes BD URINE ANALYSIS TUBE PK/100 B2953-2 BD 367988 Tiger Top Tube BD 8.5ML TIGER TOP TUBE PK/100 B2953-11 BD 367863 EDTA Tube BD K2 EDTA TUBE PK/100 364606 BD 364606 Yellow Top Tubes ACD TUBES SOLUTION A PK/100 367820 BD 367820 Red Top Tubes BLOOD COLLECTION CLOT ACTIVATOR PK/100 R05054 REMEL R05054 Cooked Meat BX/100 R064880 REMEL R064880 1ml TSB BX/100 279018 BIOMERIEUX 279018 BPA Tubes Aerobic Bottles PK/25 279019 BIOMERIEUX 279019 BPN Tubes Anaerobic Bottles PK/25 259789 BIOMERIEUX 259789 SA Tubes PK/25 259790 BIOMERIEUX 259790 SN Tubes PK/25 S60549 SARSTEDT 60.549 Sample Tubes Serum Transport Tube Any B1209-16 Zip-Pak SBL2X810B5 Bio-Bag '8x10' BIOHAZARD BAG PK/100
Requisitions:	Micro (0014 or 0015)  Serology (0012)  HLA (0013)  Stem Cell (0016)  No additional requistion forms needed
FedEx Forms:	First Overnight  Priority Overnight  No additional FedEx forms needed
Additional Comments: