subject_line
General Supply Form
Contact Information
Practice Name
*
Territory Manager
*
Phone
*
Email Address
*
Address
Street Address
*
City
*
State
*
ZIP Code
*
General Supplies
Lock Box - Small
1
Lock Box - Large
1
Tox. Training Binder
1
2
3
4
5
Clinical Training Binder
1
2
3
4
5
Synergy Stickers
1
2
3
4
5
Specimen Bags
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
Gloves - Small
1
2
3
4
Gloves - Medium
1
2
3
4
Gloves - Large
1
2
3
4
Disposable Lab Coats - Small
1
2
3
4
Disposable Lab Coats - Medium
1
2
3
4
Disposable Lab Coats - Large
1
2
3
4
Fridge Thermometer
1
Lysol Wipes
1
2
3
Lysol Spray
1
2
3
Hand Soap
1
2
3
4
5
Hand Sanitizer
1
2
3
4
5
Collector Office Supplies
Pens
1
2
3
4
5
6
7
8
9
10
Highlighters
1
2
3
4
5
6
7
8
9
10
Sharpies
1
2
3
4
5
6
7
8
9
10
Copy Paper
1
2
3
4
5
Toxicology Supplies
Blue Top Vacutainer Collection Cup
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
Toxicology Vial (Vacutainer Collection Vial)
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
Temperature Strips
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
Toxicology Requisition Form
25
50
75
100
125
150
175
200
Urine Transfer Device
100
200
300
400
500
600
700
800
900
1000
Collection Hats
10
20
30
40
50
60
70
80
90
100
Oral Swabs
10
Supplies for Purchase
Blue Top Vacutainer Collection Cup ($63.00/per 100)
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
POC 12 Panel Cups + BUP ($87.50/per 25)
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
12 Panel + BUP Dip Card ($62.50/per 25)
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
Vacutainer Vials ($7.35/per 100)
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
POC 12 Panel Cups + BUP w/o Vacutainer Lid ($87.50/per 25)
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
Temp Strips ($16.00/per 100)
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
Clinical Supplies
Clinical Requisition Form
25
50
75
100
125
150
175
200
21 Gauge Green Vacu Needles
1
2
3
4
5
22 Gauge Black Vacu Needles
1
2
3
4
5
23 Gauge Butterfly Needles
1
2
3
4
5
Lavender EDTA Vial
100
200
300
400
500
600
700
800
900
1000
Gold SST Vial
100
200
300
400
500
600
700
800
900
1000
Black ESR Vials
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
Blood - Pink Tubes (Blood Typing)
100
200
300
Tourniquet
1
2
3
4
Gauze Box
1
2
3
4
Alcohol Prep
1
2
3
4
Medical Tape
1
2
3
4
Coban Wrap
1
2
3
4
Vacutainer Holder
250
500
750
1000
Vial Rack
1
2
3
Face Shield
1
2
ABN Forms
50
100
150
200
250
300
350
400
450
500
Sharps Container - 8 Quart
1
2
3
4
Red Biohazard Bags
1
2
3
4
5
Sharps Container - 9 Gallon
1
2
3
4
24 Hour Urine Jug
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Glucola Drink, 50g.
6
12
18
24
Glucola Drink, 75g.
6
12
18
24
Glucola Drink, 100g.
6
12
18
24
Cobas Urine Collection Device (CT/NG/TV)
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
Glucola Drink, 50g (CASE)
1 (Qty 24)
2 (Qty 48)
Glucola Drink, 75g. (CASE)
1 (Qty 24)
2 (Qty 48)
Glucola Drink, 100g. (CASE)
1 (Qty 24)
2 (Qty 48)
Gray Top Vials-Urine Culture
100
200
Castile Soap Towelette (For CC Urine)
10
20
30
40
50
60
70
80
90
100
Light Blue Vials
10
Yellow UA Urine Vials
10
20
30
40
50
60
70
80
90
100
Aliquot Vials & Caps
50
Pipettes
50
Red Top Vials without Gel Separator
10
20
100
Lithium Heparin Green Top Vial without Gel Separator
10
20
30
40
50
100
Lithium Heparin Green Top Vial with Gel Separator
10
20
Shipping Supplies
Biohazard Labels
1
2
3
4
5
6
7
8
9
10
Silver Freezer Bags
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cool Packs
1
2
3
4
5
6
7
8
9
10
Small Express Boxes (UPS ONLY)
20
40
60
80
100
Courier Labels (COURIER ONLY)
10
20
30
40
50
60
70
80
90
100
Courier Bags (COURIER ONLY)
10
20
30
40
50
60
70
80
90
100
Microbiology Supplies
Microbiology ESWAB
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
185
190
195
200
Stool Collection Kit
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
100
Adult Blood Culture Kit
5
10
15
20
25
30
Pediatric Blood Culture Kit
5
10
15
20
25
30
Respiratory Supplies
Respiratory PCR Swab (GEN_RESP)
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
950
1000
Pediatric Respiratory PCR Swab (GEN_RESP)
25
50
75
100
125
150
175
200
225
250
275
300
COVID19 Single Swab Kit (RPIP & COVID)
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
850
900
950
1000
1050
1100
1150
1200
1250
1300
1350
1400
1450
1500
1550
1600
1650
1700
1750
1800
1850
1900
1950
2000
2050
2100
2150
2200
2250
2300
2350
2400
2450
2500
2550
2600
2650
2700
2750
2800
2850
2900
2950
3000
3050
3100
3150
3200
3250
3300
3350
3400
3450
3500
3550
3600
3650
3700
3750
3800
3850
3900
3950
4000
4050
4100
4150
4200
4250
4300
4350
4400
4450
4500
4550
4600
4650
4700
4750
4800
4850
4900
4950
5000
Genetic Supplies
Aptima MultiTest Swabs
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
185
190
195
200
Workstation Supplies
Laptop
1
2
Zebra Printer
1
2
3
Mouse
1
2
Epson WF-2860 Printer
1
2
3
Laboratory Centrifuge (CLINICAL ONLY)
1
2
Rolls of Specimen Cup labels (for Zebra Printer)
1
2
DYMO Printer
1
2
3
4
5
DYMO Labels 1 1/8 X 3 ½ (LARGE)
1
2
3
4
5
6
7
8
9
10
DYMO Labels 1 X 2 1/8 (SMALL)
1
2
3
4
5
6
7
8
9
10
Epson WF-2860 Black Ink 202
1
2
Epson WF-2860 Color Ink 202
1
2
HP 8610 Black Ink 950 and 951
1
2
HP 8610 Color Ink 950 and 951
1
2
HP 8710 Black Ink 952
1
2
HP 8710 Color Ink 952
1
2
HP 8015 Black Ink 910
1
2
HP 8015 Combo Ink 910
1
2
HP 9015 Color Ink
1
2
3
4
HP 9015 Black Ink 962
1
2
3
4
HP 9015 Combo Ink (Color + Black) 962
1
2
3
4
Pathology Supplies
Thin-Prep GYN Kit
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
Thin-Layer Non-GYN
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
Biopsy Container
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
Prostate Biopsy Kits
5
10
15
Brushes and Spatula
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
Brooms
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
475
500
Pathology ABN Form
50
100
150
200
250
300
350
400
450
500
Additional Supplies