Supply Request Form

SUPPLY REQUEST FORM

TO:

San Diego Pathologists Medical Group, Inc.
Courier Department

Phone: 619.297.4900
Fax: 619.297.5460

REQUEST DATE:

FROM:

HISTOLOGY SUPPLIES	CYTOLOGY SUPPLIES
Formalin Containers extra small ________ small ____________ medium __________ large ____________	PAP Collection Kit _____________
Requisition Forms __________	Fixative Cytospray ____________
Specimen Bags ___________	Cytorich Red Fixative __________
Special Fixatives B5 (bonemarrows) _______________ Bouin's (testis) __________________	Wood Scrapers ____________
	Plastic Scrapers ____________
	Cardboard Slide Mailers _________
	Plastic Slide Mailers _________

Miscellaneous Requests ____________________________________________________________

______________________________________________________________________________

Filled by: _________________________ Date: _____________________

FAX TO: 619.297.5460

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