Transcription of PLEASE EMAIL FORM TO: supplyrequest@cplse.com or you …
1 Date: Practice Name: Acct#: Contact: Address: Item Order Qty Red SST tube (each) Telephone number: Red Plain tube (each) Item Order Qty Lavender tube (EDTA) (each) Complete Urine Coll Kit (50 per box). Light Blue tube (Citrate) (each) Urine Culture Tubes - Gray (50 per box). Gray tube (each) Aptima Unisex Swab (each). Green tube (Sodium Heparin) (each) Aptima Urine Swab (each). Green tube (Lithium Heparin) (each) Aptima Vaginal Swab (each). Yellow tube A or B Solution (ACD) (each) BD Affirm (each). Plastic Transfer Tubes w/caps (each) Sterile Cups, Urine collection (each). 21 G Needles (48 per box) 24 hr. Urine Container (each). 22 G Needles (48 per box) Castille Soap Towelettes (100/pk).
2 Needle Holders (each) Small Biopsy containers (each). 21G Butterfly Needles (50 per box) Medium Biopsy containers (each). 23G Butterfly Needles (50 per box) Large Biopsy containers (each). 25G Butterfly Needles (50 per box) Glucola, 50 G (each). Co-Flex (2 rolls per pack) Glucola, 75 G (each). Tourniquet (each) Glucola, 100 G (each). Cytology Order Qty Miscellaneous Order Qty Thin Prep Kit w/brush & spatula (kit each) Clinical Requisitions Thin Prep kit w/brooms (kit each) Cytology Requisitions Surepath kit w/brooms (kit each) Pathology Requisitions Surepath kit w/brush & spatula (kit each) Allergen Requisitions Maternal Requisitions Microbiology Order Qty BioTe Requisitions ESwab (10 per box) Women's Health Versa Trek Aerobic (each) Reqs other: _____.
3 Versa Trek Ananerobic (each) Small lock box Media, M5 Viral Culture (each) Large lock box Media, Cary Blair C&S (10 per box) Bags (small biohazard specimen bags). O & P Kits (10 per box) Toner Cartridge>. Hemocult Cards (25 per pack) Make: Model: FOBT Collection Kit (kit each) Item #: Other: PLEASE EMAIL FORM TO: or you may fax it to 407-386-9077 . PLEASE do not submit supply requests to your courier. If you need assistance, have any questions regarding your supply order, or your supply order status, PLEASE contact Customer Service at 866-236-5757. PLEASE allow 72 business hours for receipt of supplies. PLEASE NOTE: All supply requests received after 2pm will not be processed until the following business day.
4 **Materials supplied are for the sole purpose of collection and transportation of specimens to CPLSE. Compliance guidelines restrict quantities that are directly related to actual volume.**. PRINT NAME : _____ REV: 05/19/17. Signature:_____ Date: _____. This form is available on our website at , under Physicians/Client forms.
