Supply Order Sheet for System Hospitals

Hospital System
Hospital Name
Attention
Requested by
Address 1
Address 2 (Department Floor)
City
State
Zip
Phone Number

Packaging Supplies QTY
Serology Boxes (Labs Inc)
Styrofoam 5-Tube Mailer
White Box w/12-Tube Mailer
Zip Loc Chart Bags, 10 X 13 (10)
Small Biohazard Bags, 6 X 9 (10)
Large Biohazard Bags 9 X 12 (10)
Padded Envelopes #5, 10.5 X 15, w/Labels 
   
Blood Tubes: (Tubes per package) QTY
Yellow Top - ACD Solution A (100)
Red Top - Serum (10)
Lavender Top - K3 EDTA 12 mg (10)
Lt. Gray Top - Sodium Floride
Potassium Oxalate 15 mg/12 mg (5)
Gold Top - SST (5)
Blood Culture Bottles - (2 of each)
   
Miscellaneous Supplies QTY
Manila Folders
Printer Label Polypropylene 2 inch
Printer Label Polypropylene 3 inch
Wristband Donor ID
Blank CD
         
ME Forms QTY
Office of ME - Hospital Report of Death **
ME Operative Report (2-page set)
Suffolk County ME Form **
   
OR Forms QTY
Confidential Donor Form (4-page set) **
   
OP Notes QTY
Cardiectomy **
Pneumonectomy **
Hepatectomy **
Hepatectomy / Pancreatectomy **
Hepatectomy / Nephrectomy **
Nephrectomy **
   
Labels for Labs (6/Sheet) QTY
Columbia Presbyterian Medical Center
Westchester County Medical Center
Montefiore Medical Center
Jacobi Medical Center
Labs Northeast
Stony Brook - SUNY Health Sciences Ctr
Mount Sinai Medical Center
Rogosin Institue (New York Hospital)
State University of NY Health Sciences Ctr
Quest Diagnostics
         
Evaluation Forms QTY
DRAI - Donor > 12 yrs (English) **
DRAI - Donor > 12 yrs (Spanish) **
DRAI ≤ 12 yrs (English) **
DRAI ≤ 12 yrs (Spanish) **
DRAI - Birth Mother (English) **
DRAI - Birth Mother (Spanish) **
DRAI - Ebola Supplement (English) **
DRAI - Ebola Supplement (Spanish) **
DRAI - Zika Supplement (English) **
DRAI - Zika Supplement (Spanish) **
   
Requisition Forms QTY
Labs - Serology Requisition w/Bar Code Label
Quest Requistion
   
Other QTY

**Please understand that forms available as electronic documents may be emailed to you
***Please allow 10-14 days for items to be shipped.