<p> Requesting Facility:______RMH - MICRO SUPPLY REQUISITION (Complete Name) City: ______Fax 320-231-4861 1-800-922-RICE (Micro ext. 4507)</p><p>Person Ordering: ______Date: ______Telephone # ______</p><p>***Large media orders not received before Monday at 8 am may not be fully filled due to current RMH stock volumes*** All orders will be filled within 1-2 days of receipt of fax and will be sent with the next available scheduled courier. ~ ~ Pricing will be updated and forwarded yearly or as needed. ~ ~ **There is a minimum charge of $2.50 on all orders placed. ** Quantity Product Quantity Product Sets *Chlamydia/GC PCR collection kits- Specify Kit : *Blood culture bottles PINK # ______Adult blood culture bottles – Cobas PCR Collection Kit ( Vaginal or Endocervical SWAB) OR (1 set = aerobic & anaerobic vial) (PINK package= Female ) or ______YELLOW # Cobas PCR URINE (YELLOW package) Male or Female (Singles) Pediatric blood culture bottles ______Quantity Quantity MEDIA supply: SPECIMEN TRANSPORT Product: List each ______Plate (s) Sheep blood agar * Anaerobic vial system – 1 E-Swab Kit *Cary blair stool culture transport media ______Plate (s) ChromAgar (20 vials in 1 case) *Coban PCR Swabs ______Plate (s) Chocolate agar (red top used for Group B Strep PCR testing) ______Plate (s) CNA agar *Double swab aerobic (routine) culturettes _____ Tube (s) LIM broth *Mini tip culturettes ______Plate (s) MacConkey agar *Single swab aerobic culturettes *UTM Transport Media ______Plate (s) SSA agar (Used for Respiratory testing: i.e. Influenza, RSV, ) *Protofix collection kits ______Plate (s) Thayer martin agar for Wet Prep for Helminths at Rice ______Tube (s) *EcoFix for Ova and Parasite Enriched Thio broth Testing at MAYO LABS MISCELLANEOUS: ______Plate (s) Standard Methods A discs Tryptic Soy Agar ______Plate(s) KOH droppers - each ( without blood) Quick strep A kit (Quick Vue +) Plated QC Organisms: List Below Other: (Please indicate by name and ATCC # which organisms are needed)</p><p>Order filled by: ______Date:______</p><p>D:\Docs\2018-04-22\099950e7139744d7f941983c29fc9b4f.doc * No charge for listed supply if testing performed by RMH </p>