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Order Supplies Form

Office Code/Name and Address*
Required by/Date*
Phone:*
Requestor Name:*
Last Order Date:

Requisitions/Bags
Requisitions (qty)
Specimen Bags (100/pk)
Transport bags LG (50/pk)
Labels for Transport bags (10/sheet)

Biopsy Collection
20 mL Formalin Jars (100/case)
90 mL Formalin Jars (100/case)
40 mL Formalin Jars (100/case)
120 mL Formalin Jars (ea)
960 mL Formalin Jars (ea)
1/2 gal Formalin Buckets (ea)
DIF/Immuno fixative (Michel's) Green Top (ea)
Labels for Jars (30/sheet)

Blood/Urine/Culture Collection
Cytology Fixative (ea)
SST (Red Tiger Top) (ea)
K2 EDTA (Lavender) (ea)
Sterile Urine Cups 90 mL (ea)
Bacterial/Fungal Culture Swabs (Pink) 1 ea
Universal Viral Transport (Purple) 1 ea

Out of State Clients
FedEx Airbills
FedEx Clinical Paks
Brown Wrap
Details (if any)

Hours & Info
Address:  28100 North Ashley Circle, suite 106, Libertyville, IL 60048
Ph:  847-996-1030  |  Fax:  847-996-0791  
Monday - Friday  |  8:00 am - 5:30 pm



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