Consumables Request Form - Magna Laboratories

Requested By
First Name*
Last Name*
Facility Name
Position
Phone
Email*
Address (please include the hospital ward and building)
Postcode
Contact Person
1. Full Blood Count kit
(routine monitoring, blue form, Vacutainer, single kit)
2. Clozapine assay kit
(plasma level, yellow form, Vacutainer, single kit)
A. Full Blood Count request form
(blue, routine monitoring, pad of 50)
B. Clozapine assay request form
(yellow, plasma level, pad of 50)
C. EDTA Vacutainer tube
(purple top, tray of 50)
D. Vacutainer needle
(green, box of 100)
E. Vacutainer tube/needle holder
(safety, bag of 50)
F. Rigid transporter for up to 3 tubes
(includes absorbent material, single)
G. Re-sealable polybags
(pack of 50)
H. EDTA Monovette tube
(red top, box of 50)
I. Monovette needles
(safety, green, box of 50)
J. Small pre-addressed mailing bag
(single)
K. Large pre-addressed mailing bag
(single, also for couriers)
L. Zaponex Patient Appointment Cards
(single)
Comments
Consent*
- I agree with the handling of my data in accordance with our privacy policy
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