donor supply request form

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Cadaveric Donor
SUPPLY REQUEST FORM
Please fax this form to ViroMedAccount Management at 336-436-1812 or
E-mail this form to [email protected]
LabCorp Account #: ______________________________________________________________________
Ordered by: __________________________________ Telephone #: _______________________________
Please complete the information below with your ship-to address:
Facility:
Attention:
Address:
City, State, Zip Code:
Supplies are routinely shipped via ground service to arrive 7 – 10 days following receipt of order.To request overnight
delivery, please provide the information below, and overnight charges will be billed to your air courier account.
Air Courier: __________________________________________ Account #: ____________________________________
Authorization: ________________________________________
Qty.
Unit
Item Name
Item #
Blood Collection Tubes
BD SST TUBE 8.5mL Plastic Tube
*39996
EA
K2 EDTA Tube 6mL (lavender top)
*39918
Specimen Containers
Serum Pour-Off Tube 3.5mL w/Cap
Controlled Ambient Transportation Kit
ViroMed Gold Specimen Transport
EA
Kit
Additional Transportation Supplies
EA
Biohazard (Ziplock) Sample Bag
Unit
Item Name
Item #
Refrigerated Transportation Supplies
EA
EA
Qty.
*23758
Please call Account Management for refrigerated transportation supply
pricing.
CS
Aqui-Pak 6-bay Absorbent
53537
EA
ViroMedNanoCool Shipping System
(Small)
*50074
Test Request Forms
EA
38644G
ViroMed Cadaveric Donor Form
(3450)
*72310
FedEx Airbills& Lab Packs
EA
FedEx Express Billable Stamp
*19818
If you have questions, please call ViroMed Account Management at 800-582-0077.
ViroMed Use Only:
Received by:____________________________________________ Received Date:____________________
Order #:_____________________ Entered by:_________________________ Entered Date: _____________
Revised January 22, 2015
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