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Order Supply Form



ChildLab provides supplies for collection of specimens (blood, body fluids, tissue) sent to ChildLab. Personalized requisitions are also available upon request. Please complete the form below to order supplies, or contact Client Services at (614) 722-5477 or (800) 934-6575. To print the completed form, right click and select print before you submit the order.

* Practice Name:
Address:
City:
State:
Zip Code:
Phone:
 
If you would like to have your order confirmed via email,
please complete both email address fields below.
Both fields must match!
Email address:
Confirm Email address:
 
 
 
Rush Delivery:

    Venipuncture Tubes
Qty Item Color Volume
(Each) Citrate Blue 2.7 mL
(Each) Citrate Blue 1.8 mL
(Each) EDTA Purple 3.0 mL
(Each) EDTA Purple 4.0 mL
(Each) Lithium Heparin Green 3.0 mL
(Each) Lithium Heparin, with Gel Green 3.0 mL
(Each) Plain Red 3.0 mL
(Each) Plain Red 6.0 mL
(Each) Sodium Flouride Gray 2.0 mL
(Each) Sodium Heparin Cytogenetics Tubes 3.0 mL
(Each) Sodium Heparin Cytogenetics Tubes 10.0 mL
(Each) SST with Gel Gold 3.5 mL
 
    Microbiology
Qty Item
(Each) APTIMA Unisex Swab Specimen Kit
(Each) APTIMA Vaginal Swab Specimen Kit
(Each) Bacterial Stool Culture (Carey Blair) Vials
(Each) Blood Culture Bottles
(Each) Charcoal Swabs
(Bag) Dual Culture Swab Systems (50)
(Each) General Viral, Chlamydia & Mycoplasma Collection Kit (M4 Media)
(Each) Midstream Urine Containers (With Wipes)
(Each) NP, Collection Swab
(Each) Ova & Parasite Kits
(Each) Pertussis/Parapertussis Collection Kit
(Each) Pinworm Collection Kit
(Each) Puritan Anterior Nares Foam Tipped Swab (Blue Label)
(Each) Puritan Posterior Nasopharyngeal Foam Tipped Applicator (Green Label)
(Each) Sterile Urine Containers(Orange Top)
(Each) Urine Bags
 
    Capillary Puncture Tubes
Qty Item Color
(Each) EDTA Purple
(Each) EDTA, with Capillary Tube Purple
(Each) Lithium Heparin Green
(Each) Lithium Heparin with Capillary Tube Green
(Each) Lithium Heparin with Gel Green
(Each) Sodium Flouride Gray
 
    Safety-Lok Needles
Qty Item Gauge Connect Type
(Each) Butterfly 21g Vacutainer
(Each) Butterfly 23g Vacutainer
(Each) Butterfly 21g Syringe
(Each) Butterfly 23g Syringe
(Each) Butterfly 25g Vacutainer
 
    Lancets
Qty Item Color Length Depth
(Each) Fingerstick Pink 1.5 1.0
(Each) Fingerstick Green 1.5 1.5
(Each) Fingerstick Blue 1.5 2.0
(Each) Quick Heel Green 2.5 1.0
 
    Other
Qty Item
(Bag) Biohazard Bags (50)
(Each) Central Ohio ChildLab Maps (100)
(Box) ChildLink sample labels
(Each) Lead Filter Paper Cards only
(Each) Lead Filter Paper Kits with biohazard bag for courier pickup
(Each) Lead Filter Paper Kits with envelope for mailing
(Each) Northeast Area ChildLab Maps (100)
(Each) Requisition Forms
(Each) Southwest Area ChildLab Maps (100)
(Each) Specimen Labels
(Each) Stat Labels
(Each) Supply Order Forms
(Each) Tourniquets
 
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