MICROBIOLOGY DX, INC.
19A CROSBY DRIVE, STE 215
BEDFORD, MA 01730
TEL: 781-276-4956 FAX: 781-276-6236
ORDER PAD - FORMS AND SUPPLIES
Account Name:
Account Number:
Date:
How Many
Item Description
Supplied
LAB REQUISITIONS
50
CYTOLOGY REQUISITIONS
50
AFP DATA SHEET
50
HIV CONSENT FORMS
50
TELEPHONE REPORT PADS
PAD/25
PRINT THIS FORM AND RETURN TO LABORATORY
PLEASE ALLOW 2 BUSINESS DAYS FOR DELIVERY
QUANTITIES MAY BE RESTRICTED