Medical supplies order form Medical supplies order form Contact name(Required) First Last Email(Required) Surgery name / Ward location(Required) Address(Required) Street Address Address Line 2 City ZIP / Postal Code REQUISITION PADS Yes please No. required (Requisition pad) Name for requisition pad BLOOD CULTURE BOTTLES Aerobic Anaerobic Paediatric Bottle adaptor No. required (anaerobic) No. required (paediatric) No. required (bottle adaptor) No. required (aerobic) NEEDLES 21 gauge (green) 22 gauge (black) No. required (21 gauge) No. required (22 gauge) BLOOD TUBES ACD 6mL CPDA 9mL Blue (citrate) 1.8 mL Blue (citrate) 2.7 mL Blue (citrate) mini-collect ESR (black) Fluoride (grey) 2mL Green (heparin) 2mL Green (heparin) 4mL Illumi (Streck) tube Lavender (EDTA) 2mL Lavender (EDTA) 4mL Lavender (EDTA) microtainer Mint (PST LH) 4.5mL Mint (PST LH) microtainer Navy (K2EDTA) 6 mL Pink (cross match) Red 2mL Red 10mL Yellow (SST) 8.5ml Yellow (SST) microtainer No. required ACD 6mL No. required CPDA tube 9mL No. required Blue 1.8mL No. required Blue 2.7mL No. required Blue mini-collect No. required ESR tubes No. required Grey 2mL No. required Green 4mL No. required Green 2mL No. required Illumi tube No. required Lavender 2mL No. required Lavender 4mL No. required Lavender microtainer No. required Mint 4.5mL No. required Mint microtainer No. required Navy 6mL No. required Pink (cross match) 6mL No. required Red tube 2mL No. required Red tube 10mL No. required Yellow (SST) 8.5mL No. required Yellow (SST) microtainer SWABS APTIMA urine chlamydia APTIMA swab chlamydia Nasopharyngeal viral collection set Routine culture swab (purple top) Urethral swab Viral dry / FLOQ swab (red top) No. required (APTIMA swab chlamydia) No. required (Routine culture swab) No. required (APTIMA urine chlamydia) No. required (Nasopharyngeal viral collection set) No. required (Urethral swab) No. required (Viral dry/FLOQ swab) SPECIMEN CONTAINERS 24-hour urine container (acid) 24-hour urine container (plain) Faeces containers (scoop) Paediatric urine bags Specimen pottles (lavender top) Urine collection punnet Urine tubes (white lid) No. required (24-hour urine container -plain) No. required (24-hour urine container – acid) No. required (Faeces containers) No. required (Paediatric urine bags) No. required (Specimen pottles) No. required (Urine collection punnet) No. required (Urine tubes) HISTOLOGY / CYTOLOGY Cervix broom (Pk/25) Endo scan + brush (Pk/10) Formalin containers (70mL) HPV self-collect swab only (Copan 552C) – Each Spatula (each) SurePath vial kit (Tray/25) Urine cytology (pottle) No. required (Cervix broom /25) No. required (Endo scan/brush /10) No. required (Formalin 70mL) No. required (HPV swab) No. required (Urine cytology pottle) No. required (Spatula) No. required (SurePath vial kit /25) SUNDRIES Alcohol wipes Biohazard specimen bags Glucose for GTT (75g) Glucose for polycose (50g) White transport bags No. required (Alcohol wipes) No. required (Biohazard specimen bags) No. required (Glucose for polycose 50g) No. required (Glucose for GTT 75g) No. required (White transport bags) OTHER REQUIREMENTSDate of order(Required) DD slash MM slash YYYY CAPTCHAUntitledFirst ChoiceSecond ChoiceThird ChoicePhoneThis field is for validation purposes and should be left unchanged. Δ
