ServiceSurgery Center Supply Form

Oral/Maxillofacial

Gastrointestinal

Surgery Center

* CLIENT NAME:

* PERSON ORDERING:

* ADDRESS:

* STATE:

Qty.

REQUISITIONS HISTOLOGY

REQUISITIONS PAP/CYTO

WHITE SHIPPING BOX(ES)

BIOHAZARD BAGS

GYNEMED BRUSH

FIXATIVES

Small Formalin

Medium Formalin

Large Formalin

6-Vial Prostate Kit

12-Vial Prostate Kit

Micheles Fixative (immunofluorescence)

Clear Prep Vial (Pap)

ACCOUNT NUMBER:

* PHONE NUMBER:

* CITY:

* ZIP CODE:

Qty.

SHIPPING SUPPLIES

FedEx CliniPaks

FedEx Next Day Labels

Check box for preprinted labels

PATIENT BILLING FLYER

COMMENTS: