Consumables Order Form Ordered by:
Position:
Practice Name: Address: Phone:
Date:
vcs Pathology Practice Number:
Email your order to stores@vcs.org.au or fax 03 9349 1977 This order form is also available at http://www.vcspathology.org.au/practitioners/consumables-order-form Liquid-based Cytology and/or HPV Testing Qty
Description (a) ThinPrep (PreservCyt® Solution) (6 pack) (a) ThinPrep (PreservCyt® Solution) (25 pack)
Cervical Cytology Qty
Qty
Chlamydia Testing
Description (b) Slide Containers (10 per pack) (c) Glass Slides (50 per pack) (d) Endocervical Brush (100 per pack)
Qty
Description (j) Flocked Swab (Chlamydia) (10 per pack) (k) Chlamydia and Pap Test Pack
Histology Qty
Collection Material (l) Histology Containers and Zip Lock Bags
Comments
(e) Spatula – Plastic (50 per pack) (f) Cervical Sampler – Broom Type (50 per pack) (g) Cervix Brush Combi (50 per pack) (h) Cytology Fixative Spray (100ml) DISPOSABLE SPECULA (i) Small (25 per pack) (i) Medium (25 per pack) (i) Large (10 per pack) image not shown
Transportation and Mailing Supplies Qty
Mailer (m) Specimen Bio Hazard Bags (100 per pack) (n) Reply Paid Envelopes (post only) (o) Pot Mailers (post only) (p) Reply Paid Satchel – Category B (post only)
Use For > all specimens > posting single slides to VCS > ThinPrep and Histology samples > single or multiple samples
Pathology Request Forms* and Information Resources Qty
Pathology Request Forms Request Forms (for computer printing) Request Forms (manual with pre-printed practitioner details) – if details are different from above see over leaf
Qty
Information Resources Pap tests and you (DL brochure) What if your Pap test result is abnormal (DL brochure) Chlamydia – What is Chlamydia? (DL brochure) Taking a Pap test (DVD) Mailing Pathology Specimens to VCS (A4 card) Chlamydia Poster PTO for images of the consumables available
Corp-Fin-F-1V10 Issued February 2016
(a) Thin Prep (PreservCyt® Solution)
(b) Slide container
(c) Glass slides
(d) Endocervical Brush
(e) Spatula – Plastic
(f) C ervical Sampler – Broom Type
(g) Cervix Brush Combi
(h) Cytology Fixative Spray
(i) Disposable Specula
(j) Flocked Swab (Chlamydia)
(k) Chlamydia and Pap Test Pack
(l) Histology Containers
Contains slide and slide container, cervical sampler and flocked swab.
PO Box 752 Swan178 Carlt on ston Phon St, South e: 03 9250 Carlton VIC 3053 0300 VIC 3053
VICTOR Reply IAN CYT OLOGY Paid CARLTO 178 SERVIC N SOU E TH VIC 3053
UN33 73 BIOLOG
ICAL
SUBSTA
NCE
S – CAT
EGORY
(m) Specimen Bio Hazard Bags
(n) Reply Paid Envelopes (post only)
(o) Pot Mailers (post only)
B
(p) Reply Paid Satchel (post only)
For detailed mailing instructions go to http://www.vcs.org.au/practices/mailing.html PO Box 752 Swa 178 Carl Phone: nston ton South VIC 3053 03 9250St, Carl 0300 ton VIC 3053
For manual request forms, please provide details below to be pre-printed on the forms for each practitioner Practitioner Name:
VICTO RIAN Reply CYTO LOGY Paid CARL 178 SERV TON ICE SOUT H VIC 3053
Practitioner Name:
UN33 73 BIOLO
GICAL SU
Practitioner Name: Practitioner Name:
BSTA
NCES
– CA TEGO
RY B