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:
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	5.0 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)	Bacterial Stool Culture (Carey Blair) Vials
	(Each)	Blood Culture Bottles
	(Each)	C.Trachomatis and N.Gonorrhoeae Aptima Unisex Swab System
	(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	Volume
	(Each)	Butterfly	21g	Syringe Vacutainer
	(Each)	Butterfly	23g	Syringe Vacutainer
	(Each)	Butterfly	25g	Syringe 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)
	(Tablet)	ChildLab Drawsite Maps (100)
	(Box)	ChildLink sample labels
	(Each)	Close to Home Healthcare Centers Maps (Brochure)
	(Each)	Requisition Forms
	(Each)	Specimen Labels
	(Each)	Stat Stickers
	(Each)	Supply Order Forms
	(Each)	Tourniquets

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