Supply Request Form
NOTE:
COVID continues to create limited availability of various medical supplies. Anticipate delays and/or lower quantities on supplies like masks, gloves, thermometers, and sanitizing wipes or gel. Thank you in advance for your understanding as we do everything we can to provide you with the items necessary to provide care to HHC patients.
Orders are shipped Mondays, Wednesdays and Fridays
(with the exception of observed holidays).
NOTE:
If an order is submitted
after
8:00 am, it will not be included in shipments going out that day, but will be fulfilled and shipped on the next scheduled shipment day.
Please take regular inventory of your supplies and order 7+ days in advance of need.
Order Type
Routine
Urgent
Date Needed By: Please note that if the request is needed prior to 5-7 business days and the visit will not be able to be completed without the supplies, to contact our office directly via Teams to coordinate the urgent shipment.
SHIPMENT INFO
RN First & Last Name
Street Address
City
Zip Code
State
North Carolina
South Carolina
Kentucky
Virginia
Georgia
Tennessee
Indiana
Washington DC
ITEMS BY QUANTITY
Lab Tubes
typically expire within 3-6 months. Please consider an appropriate quantity based on typical use and anticipated expiration.
Serum Tubes
(Gold/Tiger Top)
Specimen Cup
EDTA Tubes
(Lavender Top)
Whole Blood Tubes
(Red/Burgundy Top)
Sodium Citrate Tubes
(Light Blue)
Syringe
(10 ml)
18G Blunt Fill Needles
Butterfly Needle (23G) w/ Tourniquet
Vacutainer
Masks
Goggles/Eyewear
(Limit 1 per RN)
N95
Limit 1; Please put size (Small, Normal) in the comments
OTHER ITEMS
SMALL Gloves (Bag of ~50)
MEDIUM Gloves (Bag of ~50)
LARGE Gloves (Bag of ~50)
Hand Sanitizer Packets (Qty 10)
Alcohol Swabs (Qty 15)
Lab Labels (Full Sheet - 30 Labels)
Bio-Bags (Qty 10)
Band-Aids & Gauze (Qty 10 each)
Band-Aids & Gauze (Qty 20 each)
Thermometer
Thermometer Sleeves (Box of 50)
Sharps Container
Equipment Cleaning Wipes (Qty 5)
Ink Pens (Qty 3)
Stylus (for electronic charting)
HHC T-shirt
Small
Medium
Large
X-Large
2XL
3XL
Lanyard/Clip for ID Badge
ID Badge Replacement (Please include name and credentials exactly as they should appear on the ID Badge)
EMERGENCY / BACKUP VISIT FORMS
Electronic Charting
is the
primary & required
method for visit note documentation.
Printed Visit paperwork
should be maintained in your Car Kit for backup / emergency use in the event your device is malfunctioning or cellular data is unavailable.
Reminder that paper documentation is subject to
these
requirements.
1-Page Standard Clinical Note (Qty 15)
2-Page Standard + Infusion Record (Qty 15)
5-Page Admission Packet (Qty 5)
Supply Request Form (Qty 10)
Narrative Note (Qty 10)
Consent Form (Qty 10)
Duke Consent Form (5 Copies)
Patient Admission Brochure / Pamphlet (Qty 10)
GUIDE - Microsoft Teams
GUIDE - Director of Nursing "Know Before You Go"
GUIDE - Lab Draw Cheat Sheet (Tests & Tube Colors Chart)
Nufactor - IVIG Nursing Note (4Pgs) (5 copies)
Nufactor - Monoclonal Antibody Nursing Note (4Pgs) (5 copies)
SENTRA* Lab Requisition (10 Copies)
Additional Needs / Comments
Submit
Reset
PDF File
