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

CULTURETTE SWABS

EA

GAUZE PADS

PK/200

PAP-PAK

BX/25

THIN PREP PAP KIT

BX/25

FEMALE GENPROBES

BX/50

MALE GENPROBES

EA

ORANGE GLUCOLA 100G BOTTLE

EA

"BIOHAZARD" SPECIMEN BAGS

EA

BAND AIDS

EA

ALCOHOL PADS

BX/200

FORMALIN BOTTLES

EA

PRINT THIS FORM AND RETURN TO LABORATORY

PLEASE ALLOW 2 BUSINESS DAYS FOR DELIVERY

QUANTITIES MAY BE RESTRICTED