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

21 G 1 1/4" SAFETY NEEDLE

BX/60

22 G 1 1/4" SAFETY NEEDLE

BX/50

1 QUART SHARPS CONTAINER

EA

2 GALLON SHARPS CONTAINER

EA

SINGLE USE NEEDLE HOLDER

PK/250

TOURNIQUET

EA

PRINT THIS FORM AND RETURN TO LABORATORY

PLEASE ALLOW 2 BUSINESS DAYS FOR DELIVERY

QUANTITIES MAY BE RESTRICTED