Supply Order Form

To help us fulfill your request, please complete this form as completely as possible. If an item is not listed on any of the drop down lists, please add it to the "additional items" space at the end of the form.

(Ex: UIC Hospital)

(Ex: A-999)

(Your name)

(Enter your email if you would like a confirmation that your order was received and fulfilled.)

The categories below are multiple selection drop down lists. You can select multiple options for each category.


**PLEASE DO NOT ATTEMPT TO EXCEED THE MAXIMUM ORDERABLE QUANTITY**

(There are 100 tubes in a pack)

Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol

If you need to order 4medica Requisitions, you will find them in the "Forms" menu below.

Select or enter value
Caret IconCaret symbol

If you need Medspeed Tracking Label Stickers, please call Lab Customer Service (312-355-5800) or Medspeed (630-617-5050).

Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol

Due to supply chain challenges, there is a maximum orderable quantity of 2 boxes of CYGC urine and 2 boxes of CYGC swabs. Please do not attempt to exceed the orderable quantity or your order will be reduced.

Select or enter value
Caret IconCaret symbol

Also known as Biological Indicator

Toner

For toner requests please reach out to your designated sales rep.

Please list any supply requests that are not available above or if you need a specific quantity not available above.

Please attach anything that will help us with your request. If you have a specific supply request that is not available on the drop down lists, you can attach a photo of it here.

Drag and drop files here or

Please click the "send me a copy of my responses" option if you would like an email confirmation of your order.

Privacy Notice|Report Abuse