North Dakota Health Dept - Microbiology Division

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LABORATORY SUPPLY REQUEST

Collection and transport supplies are provided for a select number of tests. Please complete the information in the demographic section of the order form to ensure proper receipt of your supplies.

Please enter a quantity next to the supplies you wish to order. If you do not find the supplies you are looking for enter a quantity in the "Other" column at the bottom of the order form and describe the item you wish to order in the space provided.

For help ordering supplies please contact The Division of Laboratory Services – Microbiology at 701.328.6272 or email us at laboratory@nd.gov

Customer Code:
Facility Name:
Facility Address:
Facility City:	Facility State:
Facility Zip Code:
Submitted By:	Phone: Phone2 Phone3	()-
Email:

ITEM REQUESTED	QUANTITY
	Package/Box	Each
Amies Transports:
Forms:
HIV Serology Request:
Supply Request:
Test Request Form:
Aptima TM Transports - 50/box (Chlamydia/Gonorrhea Amplified Probe) Aptima TM Transports Each
O & P Transports:
Pertussis DNA Probe Transports:
Saboraud Fungus Transports:
Serology Mailer:
TB Containers (Sputum - AFB):
Urine Transports (Chlamydia/Gonorrhea Amplified Probe):
Viral Culturettes TM:
Water Bottles Community:
Water Bottles Private:
Other:		Other Each