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SUPPLY REQUEST FORM

Lower Columbia Pathologists is pleased to offer collection supplies at no charge for testing to be performed at our laboratory. Please fill out the form below and return it to LCP and your supplies will be delivered within 48 hours. If you need your supplies STAT, please indicate that below.

Date (mm/dd/yy)
Client
Completed By
STAT Delivery

Cytology		Histology
	Sure Path Kits (Vials and Brooms)		Biohazard Bags
	Sure Path Brushes		20ml Fixative Bottles
	Sure Path Cervix Brush Combi		60ml Fixative Bottles
	Pap Smear Cardboards		120ml Fixative Bottles
	Pap Pack Kits (Conventional)		Cervical Biopsy Kit
	Cytorich Red		Dermatology Kit
	Urine/Sputum/FNA Containers (with fixative)		Urology Kit
	Urine/Sputum/FNA Containers (without fixative)
	Cytology Pump Spray Fixative
	Slides (Frosted End)

Advance Beneficiary Notice		Forms/Notices
	GYN Cytology		Patient Billing Information Cards
	GYN Spanish		LCP Requisitions
	Blank Form		Supply Request Form
	Blank Spanish Form		Nuclear Medicine Map
			Spanish Negative Pap Notices
			Negative Pap Notices