Request Supplies

**Please allow 48 hours for all orders to be filled**

To submit your order via courier or fax, please use printable form.

Date of Request (required)

Requesting Office (required)

Person Ordering

Email Address

PRW Requisition Forms - 100/ per pack

Quantity:

ModMed/EMA paper with labels (pack) - 100/ per pack

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ModMed/EMA paper with labels (case) - 1000/ per case

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Specimen bags (pack) - 100/ per pack

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Labels for bottles (sheet) - 30/ per sheet

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Specimen Bottles:

20ml (sm) Formalin Jars - 96/ per case
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40ml (lg) Formalin Jars - 96/ per case
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60ml (xlg) Formalin Jars - 24/ per box
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120ml (2xl) Formalin Jars - 24/ per box
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Prostate Kits:

6 core - 1/ per kit
Quantity:
12 core - 1/ per kit
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Michel's Fixative vials (immunofluorescence testing)

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Culture Swabs - 10/ per pack

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DTM vials (Dermatophyte Test Medium) - 20/ per box

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Laboratory Info Leaflets (for patients) - 100/ per pack

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Specimen Log Forms - 25/ per case

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Printer/Copy Paper - 1 case

Quantity:

Printer Ink:

Cartridge #:
CyanMagentaYellowBlack

Additional Comments/ Requests