Office Name*

Account Number

Address*

City*

Ordered By*

Bone Marrow

15 ml RPMI

Quantity

Each

Bone Marrow Kit

Quantity

Each

Bulk Fixative

1 Gallon Formalin

Quantity

Each

1 Quart Cytology Fixative

Quantity

Each

5 Gallon Formalin

Quantity

Each

Immunofluorescence

Zeus Fixative

Quantity

Each

Non-Pap Cytology / FNA

120 ml Blue Top Cytology Fixative

Quantity

Quantity Type

30 ml Green Top Cytology Fixative

Quantity

Each

Afirma Kit

Quantity

Each

Anal Cytology Kit

Quantity

Each

Cardboard Slide Holder

Quantity

Each (holds 2 slides)

Green Top Vial with Alcohol for FNA/Non-GYN Cytology Microscope Glass Slides - Bellevue Only

Quantity

Each

Plastic Slide Holder

Quantity

Each (holds 5 slides)

Positively Charged Slides

Quantity

Box (72)

ThinPrep® PreservCyt Solution Vial

Non-GYN Cytology

Quantity

Each

ThyGeNEXT Kit

Quantity

Each

Oral Biopsy Kit

Quantity

Each

Pap Test

Brush/Spatula

Quantity

Pack of 25 (Maximum quantity 2 Packs)

Mops/Brooms

Quantity

Pack of 25 (Maximum quantity 2 Packs)

ThinPrep® with Cervix Brush/Spatula

Quantity

Quantity Type

ThinPrep® with Cervix Mop/Broom (Lavender)

Quantity

Quantity Type

Prostate

Prostate Biopsy Kit (12 vials)

Quantity

Each

Prostate Biopsy Kit (8 vials)

Quantity

Each

Requisitions

Medicare ABN Form

Quantity

Tear-off pads of 50

Requisition - Dermatology

Quantity

Pack (Qty 25)

Requisition - Gastrointestinal

Quantity

Pack (Qty 25)

Requisition - Hematology

Quantity

Pack (Qty 25)

Requisition - Histology / Cytology

Quantity

Pack (Qty 25)

Requisition - Hospital / Surgical

Quantity

Pack (Qty 25)

Requisition - Oral & Maxillofacial

Quantity

Pack (Qty 5)

Requisition - Podiatry

Quantity

Pack (Qty 25)

Requisition - Urology / 12 Part

Quantity

Pack (Qty 25)

Requisition - Urology / 6 Part

Quantity

Pack (Qty 25)

Specimen Containers (Empty)

1 Liter Specimen Container

Quantity

Each

120 ml (Blue Top) Sterile

Quantity

Each

120 ml Blue Top (Empty)

Quantity

Quantity Type

30 ml Green Top (Empty)

Quantity

Each

40 ml (Yellow Top)

Quantity

Each

400 ml (Yellow Top)

Quantity

Each

90 ml (Yellow Top)

Quantity

Each

Bucket (1 Gallon)

Quantity

Each

Bucket (1/2 Gallon)

Quantity

Each

Specimen Labeling & Packaging

Incyte Specimen Bag - 6 X 9"

Quantity

Pack (Qty 100)

Incyte Specimen Manifest

Quantity

Pack (100)

Manifest Bag

Quantity

Pack (100)

Tissue Collection Supplies

Formalin Tissue Bottle - 20 ml

Quantity

Quantity Type

Formalin Tissue Bottle - 237 ml (8 oz)

Quantity

Each

Formalin Tissue Bottle - 40 ml

Quantity

Quantity Type

Formalin Tissue Bottle - 473 ml (16 oz)

Quantity

Each

Formalin Tissue Bottle - 90 ml

Quantity

Quantity Type

Formalin Tissue Bottle - 946 ml (32 oz)

Quantity

Each

Scored Cervical Brush

Quantity

Box (Qty 100)

Tophus

20 ml 100% Ethyl Alcohol (Ethanol)

Quantity

Quantity Type

Worksheets & Handouts

Cystic Fibrosis Carrier Testing Brochure

Patient Brochure

Quantity

Each

Maternal Serum Screening Brochure

Patient Brochure

Quantity

Each

Placental Worksheet

Quantity

Tear-off pad(s) of 50

Thyroid FNA Worksheet

Quantity

Tear-off pad(s) of 50

Order Comments

We realize that we all work in an ever-changing environment. If there has been a recent change in your office that you would like us to make on your requisition or if there are any additional supplies you would like to order that are not listed above, please note it here.

Supply Usage Agreement*

I agree that, in accordance with Section 1877 of the Social Security Act (42 U.S.C. 1395) (Stark Law), all laboratory supplies provided by Incyte Diagnostics to my facility at no cost, are intended for the exclusive use in collecting, transporting, processing or storing of specimens/samples used in testing referred to and performed by Incyte Diagnostics for my patients. Any other use is strictly prohibited under this agreement. Furthermore, requests for supplies will be monitored and should not exceed an average two-month supply based on historical testing data.

* Required Fields

Order Supplies

Bone Marrow

15 ml RPMI

Bone Marrow Kit

Bulk Fixative

1 Gallon Formalin

1 Quart Cytology Fixative

5 Gallon Formalin

Immunofluorescence

Zeus Fixative

Non-Pap Cytology / FNA

120 ml Blue Top Cytology Fixative

30 ml Green Top Cytology Fixative

Afirma Kit

Anal Cytology Kit

Cardboard Slide Holder

Green Top Vial with Alcohol for FNA/Non-GYN Cytology Microscope Glass Slides - Bellevue Only

Plastic Slide Holder

Positively Charged Slides

ThinPrep® PreservCyt Solution Vial

ThyGeNEXT Kit

Oral Biopsy Kit

Oral Biopsy Kit

Pap Test

Brush/Spatula

Mops/Brooms

ThinPrep® with Cervix Brush/Spatula

ThinPrep® with Cervix Mop/Broom (Lavender)

Prostate

Prostate Biopsy Kit (12 vials)

Prostate Biopsy Kit (8 vials)

Requisitions

Medicare ABN Form

Requisition - Dermatology

Requisition - Gastrointestinal

Requisition - Hematology

Requisition - Histology / Cytology

Requisition - Hospital / Surgical

Requisition - Oral & Maxillofacial

Requisition - Podiatry

Requisition - Urology / 12 Part

Requisition - Urology / 6 Part

Specimen Containers (Empty)

1 Liter Specimen Container

120 ml (Blue Top) Sterile

120 ml Blue Top (Empty)

30 ml Green Top (Empty)

40 ml (Yellow Top)

400 ml (Yellow Top)

90 ml (Yellow Top)

Bucket (1 Gallon)

Bucket (1/2 Gallon)

Specimen Labeling & Packaging

Incyte Specimen Bag - 6 X 9"

Incyte Specimen Manifest

Manifest Bag

Tissue Collection Supplies

Formalin Tissue Bottle - 20 ml

Formalin Tissue Bottle - 237 ml (8 oz)

Formalin Tissue Bottle - 40 ml

Formalin Tissue Bottle - 473 ml (16 oz)

Formalin Tissue Bottle - 90 ml

Formalin Tissue Bottle - 946 ml (32 oz)

Scored Cervical Brush

Tophus

20 ml 100% Ethyl Alcohol (Ethanol)

Worksheets & Handouts

Cystic Fibrosis Carrier Testing Brochure

Maternal Serum Screening Brochure

Placental Worksheet

Thyroid FNA Worksheet

Supply Usage Agreement*