(Form 3)

Request for Laboratory Supplies

Please complete form and email to:

Practice Name:
Address:
Tel number: / [ / Name of person placing the order
…………………………………………
Date ………………………………..
Transfer point number
Item / Lab Use / Size/Pack / Max Order / No. Required
Request Form
Haem and Biochem forms (orange) / HB0001 / Box 500 / 1 box
Microbiology forms (blue) / MIC0001 / Pack 50 / 400
Immunology forms (brown) / IMM0001 / Pack 50 / 400
Cell Path forms (black) / CEL0001 / Pack 50 / 400
Downs Screening forms (purple) / ARF0002 / Pack 50 / 20
Haem Antenatal Forms (pink) / HAS001 / Pack 50 / 100
Micro Antenatal Forms (blue) / MAS001 / Pack 50 / 100
HLA tissue typing forms / RTH0020 / Single / 20
ICE A4 labels / 1500 per box / 1 box
Vacutainers
PST Heparin (green cap) 3ml / KFK130 / Pack 100 / 200
EDTA (purple cap) 4ml / KFK171 / Pack 100 / 200
EDTA short draw (purple cap) 2ml / KFK276 / Pack 100 / 100
SST (yellow cap) 5ml / KFK114 / Pack 100 / 200
Citrate (blue cap) 2.7ml / KFK119 / Pack 100 / 200
Citrate short draw (blue cap) 1.8ml / KFK117 / Pack 100 / 100
Fluoride-oxalate (grey cap) Glucose 2ml / KFK250 / Pack 100 / 200
Paediatric Blood Tubes:
Heparin (orange) 1.3ml / KCM108 / Single / 20
EDTA (red) 1.3ml / KCM107 / Single / 20
Plain (grey) 1.3ml / KCM106 / Single / 20
Citrate (green) 1.3ml / KCM071 / Single / 20
Fluoride-oxalate (Glucose) (yellow) 1.3ml / KCM155 / Single / 20
Miscellaneous Item
Vacutainer Needles / KFK217 / 1 pack of 48 / 4 pack
Needle Holders (vacutainers) / KFK037 / 250 per pack / 1 pack
Baby Urine Bag / GCS122 / Single / 10
MSU - Sterilin 30mL universal with quick-start cap / KCP409 / 400 / 400
Sputum Pot - Container 60ml Plastic printed label metal screw cap clinically clean Bag 50 / KCP044 / Bag 50 / 1 bag
Faecal pots - Sterilin 30mL universal with quick-start cap and spoon / KCP416 / 400 / 400

(Form 3 cont)

Page 2: Surgery name:

BAF-6000-08A CELLSTOR POT - 60ml - 10% NEUTRAL BUFFERED FORMALIN (Histology) / BAF-6000-08A / Single / 20
NAATs for Chlamydia and Gonorrhoea – (men only) (Urine transport kits) (441362 KIT UPT CT/GC QX Pack 100 from Becton Dickenson) / From Micro 441362 / Single / 40
NAATs for Chlamydia, Gonorrhoea and TV. NAATs for genital HSV. Swab for clinician taken samples. (441357 KIT FEMALE COLLECTION from Becton Dickenson) / From Micro
441357 / Single / 40
NAATs for Chlamydia, Gonorrhoea and TV Swab for a patient taken sample (441122 Swab Transport, pack 100, from Becton Dickenson) / From Micro
441122 / Single / 40
Microbiology culture (MC&S) Preferred sample type. ∑-TRANSWAB® (MWE) (Purple top) Liquid-based multipurpose collection and preservation system for micro-organisms for culture. Must be used for MRSA screening
Use for all wounds, skin and surface swabs (including eye, ear, throat, HVS, CPE (NB break shaft before using for rectal swabbing) / MW176S
Microbiology culture (MC&S) . Amies medium for the transport of micro-organisms for culture. Can be used as above for ∑-TRANSWAB® / MW171 / Single / 50
Viral studies swab (COPAN UTM Kit). (359C)
For collection and preservation of viruses for molecular testing/PCR.
Throat swabs/NPA for Influenza/RSV/Respiratory virus panel (includes Mycoplasma). Vesicle swabs for VZV/HSV (non-genital)
Eye swabs for Adenovirus, Chlamydia (non-genital) / 359C / Single / 10
Blood Culture bottles / From Micro / 2 / order as required
24 hours urine bottles (plain) / From Biochem / Single / 5
24 hours urine bottles (HCL acid red lid) / From Biochem / Single / 5
24 hour urine bottle (acetic acid black lid) / From Biochem / Single / 5
Cross-match packs / Single / 2
Pathology Specimen bags (clear) (large) / Single / 50
Pathology Specimen bags (pink) Cytology / Single / 50
Pathology Specimen bags (small) / Single / 100
Pathology Specimen bags microbiology (blue) / Single / 50
Lab Use Only / Order processed by / Date

2016 GP Order formPage 2