To request supplies

Date:


Client I.D.#:
Clinic Name:

CLINIC ADDRESS

Address:

City:

State:

Zip:

ORDERED BY

First Name:

Last Name: Phone #:



Email

MOLECULAR SUPPLIES: (Order in individual quantities unless specified by item)

MetroSwab
BD Affirm Collection System
Aptima Urine Collection Kit
Aptima Swab Collection Kit (Endocervical & male urethral specimens)
Group B Strep (GBS) (STARSWAB II)

CYTOLOGY SUPPLIES:

ThinPrep Kit (25 vials per tray: For PAPS, Molecular Testing, Breast Discharges)
Brushes & Spatulas - (25 each per bag)Brooms - (25 each per bag)
SurePath Kit (25 vials per tray)
Brushes & Spatulas - (25 each per bag)Brooms - (25 each per bag)Combi - (25 each per bag - SurePath ONLY)
30ml CytoLyt Solution Vials (For FNA Specimens ONLY: i.e. Thyroid, Lymph Node, Breast FNA/Cyst) (20/tray)
Anal Pap Kits
Urine Cytology Cups

HISTOLOGY SUPPLIES:

20ml Formalin Vials for Specimens <2cm (24 per box)
40ml Formalin Vials for Specimens >2cm (24 per box)
Prostate Biopsy Kits - 6 or 12 Formalin Vials
6 Formalin Vials12 Formalin Vials

GENERAL SUPPLIES:

Specimen Bags (100 per pack)
Requisition Forms (increments of 50)
Shipping Labels (increments of 25)
Shipping Bags (increments of 25)
Individual Shipping Bags (1-25)

 

Patient Information Brochures (25/pack – please indicate # of packs in box to the right of item)
Pap Test HPV
Abnormal Pap tests GBS
HSV
Other - Please List   

COMMENTS:

Comments:
7444 W. Alaska Drive, Suite 250, Lakewood, CO 80226

303-592-7284 Office 303-892-0601 Fax

Supply Request Form v.6 10/13/2014

 

or

Call 303-592-7284

or

Select the button below to download a blank MetroPath Supply Request Form in PDF format for printing.

Supply Request Form