Supply Request Form

Client Name

Submitted By

Date

Requisition/Forms

Specimen Receipt Log

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Medicare ABN

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Surg Path/ GYN Cyto Requisition

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Surg Path/Non-GYN Cyto Req.

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Gastrointestinal Pathology Req.

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Oral/Maxillofacial Req.

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Dermatopathology Req.

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Podiatry Req.

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Specimen Labels — 30/sheet

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Specimen Supplies

Transport Bags 6x9 — Each

Quantity:

Transport Bags 6x9 — Pack/100

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Urine Containers

Urinalysis Only

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Urinalysis + Culture

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Pathology Supplies

165 oz / 1.2 gal (breast reduction / placenta) Container

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Prefilled Formalin

10 mL Container — Each

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10 mL Container — Box/24

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20 mL Container — Each

Quantity:

20 mL Container — Box/24

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40 mL Container — Each

Quantity:

40 mL Container — Box/24

Quantity:

60 mL Container — Each

Quantity:

60 mL Container — Box/24

Quantity:

90 mL Container — Each

Quantity:

90 mL Container — Box/24

Quantity:

120 mL Container — Each

Quantity:

120 mL Container — Box/24

Quantity:

240 mL Container — Each

Quantity:

480 mL Container — Each

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Cytology Supplies

Thin Prep Vials — Tray/25

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Thin Prep Vials — Box/250

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Spatula and Brush Sets — Bag/25

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Purple Broom — Bag/25

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Transport Media

e-Swab White Anaer/Aer — Each

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Naso Swab — Each

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Naso Swab — Each

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One Swab — Each

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Michel’s / Zeus medium (for DIF)

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RPMI medium (for flow cytometry)

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Other Supplies

Item

Quantity

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Pennsylvania Specialty Pathology