GEORGIA PUBLIC HEALTH LABORATORY

SPECIMEN COLLECTION OUTFIT ORDER FORM

1751 Gus Karle Parkway, Waycross GA 31503
Waycross Lab Service and Supply Phone: 912-338-7050 Fax:912-338-7061

INSTRUCTIONS: Please fill out this form completely and legibly. For the quantity, write the total number of kits/items needed. For
example, if you need 100 gold top tubes, enter the quantity as 100 next to the item number 0590. Fax the completed order form
to 912-338-7061. If you are not sure about what to order, call us. We are happy to help you figure out how to best order what you
need. We process orders daily in the order they are received. It may take up to 10 days to receive your order. Please remember,
the supplies provided by the Georgia Public Health Laboratory(GPHL) should only be used for specimens submitted to the
GPHL.

SUBMITTER INFORMATION(Required)
Company Name Contact Phone Number

Street Address (NO PO Boxes) Suite City State Zip

Serology Outfits and Components Mailing Cans/Lids and Individual Components

ITEM QUANTITY DESCRIPTION ITEM QUANTITY DESCRIPTION
0500 EA 5ml Gold Top SST 3597 EA Green Mailing Label

0800 EA Biohazard Specimen Bags with

Absorbent Paper
0801 EA Fiberboard Cans/Lids

Lead Supplies Miscellaneous

ITEM QUANTITY DESCRIPTION ITEM QUANTITY DESCRIPTION
0605 EA Capillary Blood Tube EDTA Purple EA
Top
3583 EA Lead Screening Form

GEORGIA PUBLIC HEALTH LAB USE ONLY: FILLED BY:

DATE RECEIVED NO. of BOXES

DATE SHIPPED

The GPHL Submission Forms are also available on the Department of Public Health Website: http://dph.georgia.gov/lab/.