Salem Hospital Regional Laboratory Services
PH: (503) 561-5390
PH: (800) 562-7542
Fax Orders to: (503) 561-2593

SUPPLY REQUEST FORM

Please deliver to:
Phone:  
Ordered by:
Order Date:  
Date Filled:  
BLOOD COLLECTION SUPPLIES
GENERAL SUPPLIES
Vacutainer, 2.7 ml blue top (100 tray)
Urine Kit - Sterile cup, C&S w/ straw, UA pres. tube
Vacutainer, 4.5 ml green top (100 tray)
(kits come in bags of 10 kits ea.)
Vacutainer, 4.0 ml lavender top (100 tray)
4oz. Urine container, sterile (no preservative) (bags of 25 ea.)
Vacutainer, 5 ml gold top (100 tray)
BD Urinalysis Preservation Tubes (ea) (yellow and red top)
(Serum separator tube, no anticoagulant)
BD Urine Transfer Straw w/ C&S tube (ea) (gray tube)
Vacutainer, 6 ml red top (100 tray)
24 Hr Urine Container (ea)
(No anticoagulant)
Salem Hospital Speciman transport bags (pkg of 100)
Vacutianer Needles, 21 gauge (100 box)
Regular Speciman (Quart)
Large (Gallon)
Vacutainer Needles, 22 gauge (100 box)
Slides, (frosted on one end) (box)
Needle holders, disposable (25 per bag)
Gonorrhea/Chlamydia collection kit (CT/NG Swab)
MICROBIOLOGY SUPPLIES
CYTOLOGY SUPPLIES
Blood culture bottle (Aerobic)
Pap kit, Sure Path (1 tray / 25 ea)
Blood culture bottle (Anaerobic)
Sure Path Brushes/Spatula (1 pk/25 ea)
Blood culture bottle (Pediatric)
Brooms, Blue Sure Path (1 pk/25 ea)
Blood Culture collection Insert
(for use when collecting tubes after blood culture)
Pap kit, Thin Prep (1 tray/25 ea)
Aerobic transport (E Swab) (EACH)
Thin Prep Brushes/Spatulas (1 pk/25 ea)
(E Swab replaces Bacti Swab)
Brooms, Purple Thin Prep (1 pk/25 ea)
Stool collection kits with instructions
Universal Transport media (herpes)
Slide mailer, 5-slide plastic (ea)
RSV & Influenza A/B Collection Kits
Pap spray fixative (ea)
Pertussis Collection Kits
Tubes w/ CytoLyte solution 50ml (ea)
BD Affirm (Box of 10)
Pap slide holders w/ alcohol (1 pk/10 ea)
FORMS
PATHOLOGY SUPPLIES
Laboratory Test Requisitions
1 oz. formalin in 30 ml container (1 tray/36 ea)
Cytology Requisitions
2 oz. formalin in 60 ml container (1 tray/25 ea)
Pathology Requisitions
4 oz. formalin in 120 ml container (1 tray/25 ea)
Supply Request Form
Formalin bottles, 1 gallon
Printer Paper (pink and white)
Specimen container, 8 ounce
NextGen Printer Paper
Specimen container, 16 ounce
Specimen container, 32 ounce
Specimen container, 1/2 gallon
Specimen container, 1 gallon
TONER (please write in toner cartridge # and printer model number)
OTHER
Send completed form with courier or fax to: 503-561-2593
Provision of Supplies and Equipment
It is our policy to provide supplies and equipment directly related to the services we provide for our clients. Services and supplies to be used by clients for other pruposes will either be billed at fair market value or we will provide a referral to high quality independent vendor.