Laboratory Supply Request Form - Naples Pathology Associates
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14351 Tamiami Trail N
Naples FL 34103
·
Phone: 239-263-1777
Fax: 239-263-6983
·
LABORATORY SUPPLY REQUEST FORM
CLIENT: ____________________________________
DATE REQUESTED: _________________
____________________________________
REQUESTED BY: ___________________
____________________________________
PHONE: ____________________________________
FAX: ______________________________
NPA Staff Use Only
ORDER TAKEN BY: ________
DATE PROMISED: _______________
FILLED BY/DATE: ____________________
PATHOLOGY
CYTOLOGY
____ BIOPSY REQUISITIONS
____ CYTOLOGY REQUISITIONS
____ 20 ML BIOPSY (FORMALIN) CONTAINERS
____ PAP KITS (Conventional)
____ 40 ML BIOPSY (FORMALIN) CONTAINERS
____ PAP HOTLINE CARDS
____ 120 ML BIOPSY (FORMALIN) CONTAINERS
____ THINPREP BOTTLES
____ FROZEN SECTION (SALINE) CONTAINERS
____
SPATULAS (ThinPrep)
____ DIF (MICHEL'S) TRANSPORT MEDIA CONTAINERS
____
PURPLE BROOMS (ThinPrep)
____ BREAST FIXATION TIME LABELS
____
BRUSH (ThinPrep)
____ 1 GALLON FORMALIN
____ ONESWAB® VIALS
____ SPECIMEN BAGS
____ UROSWAB® VIALS
____ SUPPLY REQUEST FORMS
____ SLIDES & SLIDE HOLDERS (non-Gyn specimens)
____ LOCKBOX
____ CYTOLYT BOTTLES (non-Gyn specimens)
LARGE BIOPSY CONTAINERS (EMPTY) -
____
1 QUART, HALF GALLON, GALLON
____ DRY KERATIN SPECIMEN BAGS
OTHER: ____________________________________________________________________________
Netdata\FORMS\SupplyRequest rev 3/16
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