Supply Request Form
Orders will be delivered
within 3-4 business days depending
on courier route schedule
12750 Erickson
Avenue Downey,
CA 90242
(562) 658-1300
Fax orders to (562) 401-5985
Email orders to: PHLstoreroom@ph.lacounty.gov
Shipping and Receiving Unit
(562) 658-1446
Health Facility/Clinic
Ordered by
Date order submitted
Address
Room number
Phone
Internal use only
Date order filled
Order filled by
Comments
Item
QTY.
ordered
QTY.
sent
Item
QTY.
sent
SAFTPAK
Culture ID Mailer
QTY. 1/each
Check kit type:
Category A (UN2814)
Category B (UN3373)
Hologic
®
Aptima Kits (CT/GC)
QTY. 50/box
Check kit type:
Urine (yellow)
Unisex 2-swab (purple)
Vaginal/Extra-genital (orange)
BD
Universal Viral
Transport Media
(STD/Influenza/Respiratory/
Other Viruses)
QTY. 1/each
Specimen Collection Containers
Check type:
Sputocol
Sputum Collection
System QTY. 72/cs
90 ml Sterile Cup (urine)
QTY. 100/bag
Biohazard Specimen Bags
(5 x 8.5”) QTY. 50/pack
Amies Transport Swab
QTY. 1/each
10% Formalin Vial
QTY. 1/each
Regan-Lowe Transport Media
w/ N.P. swab QTY. 1/each
HIV-1 Viral Load Plasma Storage
Tubes & Caps QTY. 100/bag
Neisseria gonorrhoeae Culture Plate
(InTray™GC) QTY. 1/each
Quantiferon Plus Blood Tube Kit
QTY. 25/pack
Para-pak® C&S Enteric
Transport Media QTY. 20/pack
Pinworm Paddle
QTY. 1/each
Para-pak® Clean Vials
QTY. 20/pack
Specimen Source Labels
QTY. 760/roll
Check label type:
Vaginal (orange)
Rectal (blue)
Throat (purple)
Plasma (green)
Trichomonas (pink)
Special Handle (pink)
Urethra (orange)
Z-PVA Parasitology Transport Media
QTY. 25/pack
Puritan® Calcium Alginate Swab
(Urethro-Genital) QTY. 50/bx
Other:
(Rev. 8/2019)
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