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

4 ML SERUM SEPARATOR

BX/100

3 ML LAVENDER TOP

BX/100

4.5 ML BLUE TOP

BX/100

6 ML RED TOP

EA

6 ML SERUM SEPARATOR

EA

10 ML SERUM SEPARATOR

EA

PRINT THIS FORM AND RETURN TO LABORATORY

PLEASE ALLOW 2 BUSINESS DAYS FOR DELIVERY

QUANTITIES MAY BE RESTRICTED