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MORE FOR YOU As the leading regional medical center in the Willamette Valley, Salem Hospital provides a broad range of top health services to the community.

Supply Request Form     Office Name or Lab* Name of person ordering Delivery Address* City* State* Zip Code* Phone Number with area code* Date Needed * Required fields Item Quantity Blood_Collection_Supplies Vacutainer, 4.5 ml blue top (100 tray) (Anticoagulant: sodium citrate) Vacutainer, 4.5 ml green top (100 tray) (Anticoagulant: lithium heparin) Vacutainer, 4.0 ml lanvendar top (100 tray) (Anticoagulant: EDTA) Vacutainer, 7 ml red top (100 tray) (No anticoagulant) Vacutainer, 5 ml gold top (100 tray) (Serum separator tube, no antigoagulant) Vacutainer needles, 21 gauge (100 box) Needle holders, disposable (25 per bag) Cytology_Supplies Pap kit, 1 slide (1 box/25 each) Pap kit, Thin Prep® (1 tray/25 each) Thin Prep® Brushes (1 pk/25 each) Thin Prep® Spatulas (1 pk/25 each) Thin Prep® Brooms (1 pk/25 each) Sure Path™ Pap kits (1 pk/25 each) Sure Path™ Brushes (1 pk/25 each) Sure Path™ Spatulas (1 pk/25 each) Sure Path™ Brooms (1 pk/25 each) Brooms, purple (1 pk/100 each) Slide mailer, 5-slide plastic (each) Milex® Spatulas (1 pk/50 each) Pap spray fixative (each) Tubes w/Saccomanno's solution (each) Pap slide holders w/alcohol (each) Saccomanno's solution, 1 gallon Forms Laboratory test requisitions Cytology requisitions Pathology requisitions Supply Request Form General_supplies Urine container, sterile (no preservative) each Urine container with preservative (1 bg/25 each) Slides, (1 side frosted) (box) Specimen transport bags (1 pack). Indicate size below. Size Small (Quart) Size Large (Gallon) 24 hr urine container (each) Gen-Probe® collections kits (each) Indicate Male Female Microbiology_Supplies Blood culture bottle (Aerobic) Blood culture bottle (Anaerobic) Blood culture bottle (Pediatric) Anaerobic transport media (1 bx/10 each) Aerobic transport (Culturette) (each) Stool collection kits with instructions Viral culture media (each) Pathology_Supplies 1 oz. formalin in 30 ml container (1tray/36 each) 2 oz. formalin in 60 ml container (1 tray/25 each) 4 oz. formalin in 120 ml container (1 tray/25 each) Formalin bottles, 1 gallon Specimen container, 8 ounce Specimen container, 16 ounce Specimen container, 32 ounce Specimen container, 1/2 gallon Specimen container, 1 gallon Other Comments

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