Order Supplies Supply Requisition Form for Doctors Items supplied are restricted and can only be used for pathology sample collection and transportation. Doctor and Medical Centre Order FormPractice/Client Name*Delivery address* Street Address City ZIP / Postal Code Phone number*Email order confirmationEnter an email address if you require a copy of your order. Enter Email Confirm Email Name of person placing order?*Date Date Format: DD slash MM slash YYYY Vacutainer CollectionVacutainer Needle Holders - Pkt/250Vacutainer Needle - Green (21g) Box/100Vacutainer Scalp Vein / Butterfly Needle CollectionPlease Note: Blue Luer-Lok multi sample adapters are now supplied pre-packaged with a needle holder (barrel). Please ensure you order the corresponding barrel to the type of Vacutainer needle.Vacutainer Needle Holder with Luer-Lok Multi Sample Adapter - 200/PktButterfly/Scalp Vein Needle - Green (21g) Box/50Butterfly/Scalp Vein Needle - Blue (23g) Box/50Syringe NeedlesSizes suitable for blood collection use. No other sizes are permitted to be supplied.Syringe Needle - Green (21g - 0.8mm x38mm) Box/100Syringe Needle - Blue (23g - 0.6mm x 32mm) Box/100SyringesSizes suitable for blood collection use. No other sizes are permitted to be supplied.Syringes (5mL) Box/100Syringes (10mL) Box/100Syringes (20mL) EachBlood Collection TubesGOLD - 5mL gel (SST) Tray/100BLUE - 2.7ml (Sodium Citrate) Tray/100PURPLE - 5ml (EDTA) Tray/100PURPLE - 10ml (EDTA) Tray/100GREY- 4ml (Glucose) Tray/100DARK BLUE - 6ml (Trace Elements) IndividualPEARL (PPT) - 5ml (K2 EDTA) IndividualYELLOW - 6ml (ACD) Tray/50LIME - 4.5ml (LH Lithium Heparin) IndividualGREEN - 6ml (NH Sodium Heparin) IndividualRED - 10ml (Plain Tube) IndividualBlood Culture Bottles (Aerobic/Anaerobict) SetQuantiferon Gold PLUS (4 Tube) Collection KitBLACK - 5ml (ESR) Tray/100For use by clients referring to Moree / Narrabri Rural LaboratoriesSwabsBlue Transtubes + Media (Micro, Culture & Sensitivity, MC&S)Orange Transtube (Male Urethral + ENT MC&S)Copan (Red) UTM Flocked Swab (Viral PCR's, Pertussis PCR)(Standard sized flocked UTM swab tip)Cobas Chlamydia / Gonococcal PCR Swab (only for these tests)Male Urethral Swab Bundle for Genital Multiplex PCR + Genital MC&S1 x Red UTM male urethral (mini-tip) swab for PCR. 1 x Orange male urethral swab for MC&S. Cytology - Cervical Screening TestCervical Screening Test Kit - EachCervix Brushes - Pkt/50Cervical Spatulas (Plastic) EachEndoscan (Cyto) Brushes - Box/100COPAN FLOQswabs (self collect) - Box/100Thin Prep Vials (LBC) - Pkt/25Lubricating Jelly 42 gram - Tube (For use in cytological exams only)Lubricating Jelly Satchels 3 gram - Box 150 (For use in cytological exams only)SpeculumPLEASE INDICATE WHICH TYPE OF SPECULUM YOU REQUIRE AND THEN THE QUANTITY FOR EACH SIZEPlease select the type of speculum Viking Artarmon Tool (Click type) EOS Med (Screw type) Welch Allyn KleenSpec Quantity SMALL Speculums - Box/24Quantity MEDIUM Speculums - Box/24Quantity LARGE Speculums - Box/20Specimen ContainersYellow Top Sterile Jar (Urine/Fluids)Brown Top Sterile Jar (Faeces)Histology Red Top Formalin Jar (10%) - Tray/2024 Hour urine bottles (Urea/Protein/Creatinine)24 Hour urine bottles with acid (Catecholamines)Fungal Collection ContainerPaediatric Urine BagsBagsSpecimen Bags - Pkt /100Contaminated Waste Bags - Pkt/25Sharps Collection ServiceA service is available to clients of SydPath for the removal of medical sharps which are specifically generated from the collection of pathology samples. Please contact SydPath Client Support on (02) 8382 9116 or SydPath.Enquiry@svha.org.au to enquire about this service.Additional Pathology Collection SuppliesAlcohol Prep Pads - Box/200Cotton Wool Balls - Bag/500Spot Bandaides - Box/100Tongue Depressors (for use in throat swab collection only) - Box/100Glucose Drink for GCT's (50g Load)Glucose Drink for GTT's (75g Load)C14 Urea Breath Test Kits (Balloon)C13 Urea Breath Test Kits (Tubes) can be ordered by special request (02) 8382 9242Punch BiopsyPlease enter quantity needed.1mm2mm3mm4mm5mm6mm8mmDermal CurettePlease enter quantity needed.2mm3mm4mm5mm7mmBiopsibladePlease enter quantity needed.Gloves (Supplied for specimen collection use only)Extra Small - Box/100Small - Box/100Medium - Box/100Large - Box/100StationeryA4 Computer Request Forms - Available in packets of 250Blood Transfusion Request Forms - Pad/50Blood Transfusion Tube Label - Roll/250Additional ItemsAdditional items may be requested here (Approval of items subject to Health Insurance Act guidelines for Permitted Benefits)Listed Items updated 16/02/2018 by SydPath Client Services (02) 8382 9116PLEASE NOTE:By pressing the SUBMIT button you agree that the ordered items are only intended to be used for the collection and transportation of pathology samples as set out in the Health Insurance Act and associated guidelines.