Reference Lab Client Order Form

Call Mattoon Lab with questions:
217-258-4005 or Toll Free 1-800-573-1940

DO NOT order here if you are a SBL Clinic.

* indicates a required field.

Client Name: *

City: *

Person requesting supplies: *

Email: *

Date ordered: *
example 01/10/16

Collection Tubes

Blue Top 2.7 mL Flat(s):
Flat(s)

Blue Top 2.7 mL:
Each

Gold Top (SST) 5 mL Flat(s):
Flat(s)

Gold Top (SST) 5 mL:
Each

Lavender 3 mL Flat(s):
Flat(s)

Lavender 3 mL:
Each

Pink Top (Blood Bank only):
Each

Red Top 6 mL:
Each

Amber pour off tubes:
Each

Clear pour off tubes:
Each

TB Quant (set of 4):
Each

Collection Needles

21G x 1" Needle:
Box(es)

21G x 1.5" Needle:
Box(es)

22G x 1" Needle:
Box(es)

22G x 1.5" Needle:
Box(es)

23G x 3/4" Safety Butterflies:
Only one box per request

Urine Containers

Urine/Stool specimen container:
Each

24 Hr urine container:
Each

Pedi bags (ubags):
Each

Specimen collections hats:
Each

Pap Smear

SurePath Pap Kits - Flat(s):
Flats(s)

Spatula/wire brush (SurePath):
Pkg(s)

Broom brush (SurePath):
Pkg(s)

ThinPrep Pap Kits - Flat(s):
Flat(s)

Spatula/Wire brush (ThinPrep):
Pkg(s)

Broom brush (ThinPrep):
Pkg(s)

Cytology

Cytolyt (Liter bottle):
Liter bottle

Cytolyt 30mL cup (single use):
Each

Slide transport containers:
Each

Charged Slides (Box):
Box

Charged Slides (Set of 5):
Sets of 5 slides

95% Alcohol:
1 liter

Pathology

(Formalin Filled)

20mL: (Each):
Each

20mL: (Box):
Box

40mL: (Each):
Each

40mL: (Box):
Box

60mL: (Each):
Each

60mL: (Box):
Box

120mL: (Each):
Each

120mL: (Box):
Box

Additional Pathology Supplies:
See Pathology Dept.

Microbiology

C&S Stool Transport Vial:
Each

AlcorFix Transport (O&P):
Each

Blood Culture Kits - Adult:
Each

Blood Culture Kits - Peds:
Each

HSV swab kit:
Each

Aptima multi-test swab kit:
Each (For ARVP sendouts only)

CHL/GC Xpert Swab kit:
Each

Routine Culture Swab - Single:
Each

Routine Culture Swab - Double:
Each

Covid VTM:
Each

Nasal Swabs For Covid Test:
Each

Nasopharyngeal Swabs for Covid Test:
Each

Vaginitis Screen Kit (BD Affirm):
Each

Forms

Reference Lab Requisition (Pkg of 25):
Pkg(s)

Surgical Pathology Requisitions:
Each

Cytology Requisition:
Each

Miscellaneous Supplies

Biohazard Specimen Bags:
Pkg(s)

Latex-Free Tourniquets:
Each

Large Clear Sharps:
Each

Medium Clear Sharps:
Each

Small Red Sharps:
Each

Safety vacutainer hub:
Bag(s)

Alcohol prep wipes:
Box(es)

Paper:
Ream

Color:
Please choose between white or yellow

Toner/Ink:
Each - You must also included Cartridge Number below.

Cartridge number:

Atlas labels:
Roll

Other supplies not listed:

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