Cadaveric Donor SUPPLY REQUEST FORM Please fax this form to ViroMedAccount Management at 336-436-1812 or E-mail this form to ViroMed_AcctMgmt@LabCorp.com 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