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
VCS Courier and Mailing Supplies Qty
(a) ThinPrep® (6 Pack)
Description (j) Specimen Bio Hazard Bags (100 per pack) > Use for all specimens
(k) Reply Paid Satchel (post only)
(a) ThinPrep® (25 Pack)
> Use for multiple specimens
(l) Zip Lock bag with liner > Use for cervical and histology specimens
(b) SurePath (TM) (6 Pack)
Pathology Request Forms
(b) SurePath (TM) (25 Pack)
Sampling Devices
Request Forms (for printing)
(c) Flocked Swab (10 per pack) (d) Cervical Sampler – Broom Type (50 per pack) (e) Endocervical Brush (100 per pack) (f) Spatula – Plastic (50 per pack) (g) Cervix Brush Combi (50 per pack) SPECULA (h) Small (25 per pack)
Request Forms (manual pre-printed with practitioner details) – see below
Information Resources Results Brochures – What do my results mean? (order max 100) Low Risk Intermediate Risk Higher Risk Unsatisfactory Chlamydia – What is Chlamydia? (DL brochure) Chlamydia & Gonorrhoea Testing & Collection Methods Chlamydia Poster Cervix Sampling Card How to take your own HPV test (Pad of 25) Indicate language required (if other than English):
(h) Medium (25 per pack) (h) Large (10 per pack) image not shown
Self Collection (c) Flocked Swab (10 per pack)
Histology (i) Histology Containers (tray of 10)
Sending Pathology Specimens to VCS (A4 card) Triple bag system for liquid based cytology For detailed mailing instructions go to www.vcs.org.au/ practices/mailing.html For manual request forms, please provide details below to be pre-printed on the forms for each practitioner
(a) Thin Prep®
(b) SurePath (TM)
(c) F locked Swab
(d) C ervical Sampler – Broom Type
(e) Endocervical Brush
(f) Spatula – Plastic
PO Box 178 Carlto 752 Swans n South Phone ton : 03 9250St, Carlto VIC 3053 n VIC 0300 3053
VICT ORIA N Repl y Paid CYTOLOGY CARLTON 178 SERV ICE SOUTH VIC 3053
UN337 3 BIOL OGIC AL SUB
STAN
CES
– CATE
GOR
(g) Cervix Brush Combi
(h) Specula
Practitoner Name:
Provider No:
Practitoner Name:
Provider No:
(i) Histology Containers
(j) Specimen Bio Hazard Bags
YB
(k) Reply Paid Satchel (post only)
Comments: PO Box 752 Swan178 Carlt on ston Phon St, South e: 03 9250 Carlton VIC 3053 0300 VIC 3053
Corp-Fin-F-1 V13 Issued June 2021 VICT ORI Reply AN CYT OLOGY Paid CARLTO 178 SERVICE N SOU TH VIC 3053
(l) Zip Lock Bags with liner