1716 W. Holt Ave. Pomona, CA      
Telephone  909-623-9301  Please FAX the completed form to 909-622-1690
Clinic:         Client #:     Date:    
Requested By:        Courier:       
100 Requisition Form Non-Cytology     1 Each Fruit Punch 50g    
100 Requisition Form With Cytology     1 Each Fruit Punch 100g    
100 SOFP and/or PE Requisition Forms     1 Each Orange 50g    
1 Box Laser Report Paper     1 Each Orange 75g    
BLOOD COLLECTION:     1 Each Orange 100g    
50 Box Serum Separator Tubes 4mL         CYTOLOGY:  
50 Box Serum Separator  Tubes 9mL       25 Thin Prep Vials    
50 Box Lavender Top Tubes 3mL     25 Brush & Spatula    
50 Box Lavender Top Tubes 4mL     25 Brooms    
50 Box Grey Top Tubes 4mL     50 / Box OB Towelettes    
50 Box Blue Top Tubes 4mL            
50 Box Plain Red Top Tubes 4mL            
50 Box Plain Red Top Tubes 10mL            
1 Each Royal Blue: EDTA or TRACE ELEMENT       HISTOLOGY:  
1 Each Green Top Sodium Heparin Tubes     1 Each Biopsy Bottles:     Small     
1 Each Green Top Lithium Heparin     1 Each Biopsy Bottles:     Medium    
1 Each Yellow Top Tubes: Solution A or B     1 Each Biopsy Bottles:     Large    
1 Kit QuantiFERON-TB Gold (3 Tubes per Kit)       URINE COLLECTION:  
NEEDLES:     1 Each Urine Cups:    Sterile    
50 Box 21g  Blood Draw Needles     1 Each Urine Cups:    Non-Sterile    
50 Box 22g  Blood Draw Needles     1 Each 24hr Urine Containers    
1 Each 23g  Butterfly Blood Collection     1 Each Urine Tube (Culture & Sensitivity)    
25 / Bag  Needle Holders       MISCELLANEOUS:  
1 Each Tourniquet     100 / Box Alcohol Wipes    
CULTURE MEDIA:     50 / Box Band Aid Regular    
1 Each Culture Swabs:  Clear     500 / Bag Cotton Balls    
1 Each Aptima CT/GC Collection Kit     1 Roll Paper Tape    
1 Each AFP Kits     100 / Bag Specimen Bags    
1 Each Viral Culture Media (M4) Male or Female     1 Each Sharp Container 2 Gallon    
1 Set Ova & Parasites Kit     1 Each Sharp Container 7 Gallon    
10 cards Occult Blood Slides       OTHER REQUESTS  
1 Set(2Bot) Blood Culture Bottles            
1 Bottle Blood Culture Bottles (Pediatrics)            
1 Set   Kilit Ampules            
1 Each Wet Mounts            
1 Each Stool Culture Transport Media            
1 Each BD Affirm Vaginal Sample Collection            
       * These supplies are to be used for FOUNDATION LABORATORY related services ONLY.
       ** Please allow 3-4 business days for delivery of supplies.