Form InorgTox501 "Order Form for Blood Lead Testing Supplies for Medical Providers" - Vermont

What Is Form InorgTox501?

This is a legal form that was released by the Vermont Department of Health - a government authority operating within Vermont. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the Vermont Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form InorgTox501 by clicking the link below or browse more documents and templates provided by the Vermont Department of Health.

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Download Form InorgTox501 "Order Form for Blood Lead Testing Supplies for Medical Providers" - Vermont

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Vermont Department of Health Laboratory
359 South Park Drive, Colchester VT 05446
[Mailing: PO Box 1125, Burlington, VT 05402-1125]
1-800-660-9997 (VT only) or 1-802-338-4736
LAB USE ONLY:
Order Submitted by (init.) _______ Date ___________
Order Filled by (init.) ______ Date____________
Order Form for Blood Lead Testing Supplies for Medical Providers
Name of Person Placing Order: __________________________________________________
Name of Practice or VDH District Office: ___________________________________________
UPS Shipping Address (no P.O. Boxes, please): ____________________________________
___________________________________________________________________________
Telephone Number: _______________________
Number
How Supplied
Description
of Units
Capillary collection kit:
Pack of 100
Microvette tubes with EDTA (lead prescreened),
No partial packs
biohazard labeled small zip-lock bags with ID label (for full name, DOB
and Collection Date - required to match test request form)
Venous collection kit:
Each
purple top vacuum tube with EDTA (lead prescreened),
biohazard labeled zip-lock bags with ID label,
aluminum tube and cardboard pre-paid mailer
Pack of 100
Extra Biohazard labeled zip-lock bags
with ID label for name, DOB, date of collection, for use with Microvette
No partial packs
tubes.
Each
Medium cardboard, pre-paid mailing tubes (capacity 2 samples)
Max order of 50
Each
Large cardboard, pre-paid mailing tubes (capacity 6 samples)
Max order of 50
Test Request Form:
One per order
VDHL Blood Lead Test Requisition Form (Inorg/Tox 200)
Sample Collection Instructions:
One per order
Technique for Capillary Blood Lead Sample Collection (Tox 430A)
Supply Order Form:
One per order
Order Form for Blood Lead Supplies (InorgTox 501)
* Microvette tubes expire as indicated on the container.
If you have single units and more than one year has elapsed since your last order, please replace
your capillary tube supply.
You can mail this form to the laboratory or fax to 1-802-338-4706.
InorgTox 501 Rev 2 (9/2021)
Page 1 of 1
Vermont Department of Health Laboratory
359 South Park Drive, Colchester VT 05446
[Mailing: PO Box 1125, Burlington, VT 05402-1125]
1-800-660-9997 (VT only) or 1-802-338-4736
LAB USE ONLY:
Order Submitted by (init.) _______ Date ___________
Order Filled by (init.) ______ Date____________
Order Form for Blood Lead Testing Supplies for Medical Providers
Name of Person Placing Order: __________________________________________________
Name of Practice or VDH District Office: ___________________________________________
UPS Shipping Address (no P.O. Boxes, please): ____________________________________
___________________________________________________________________________
Telephone Number: _______________________
Number
How Supplied
Description
of Units
Capillary collection kit:
Pack of 100
Microvette tubes with EDTA (lead prescreened),
No partial packs
biohazard labeled small zip-lock bags with ID label (for full name, DOB
and Collection Date - required to match test request form)
Venous collection kit:
Each
purple top vacuum tube with EDTA (lead prescreened),
biohazard labeled zip-lock bags with ID label,
aluminum tube and cardboard pre-paid mailer
Pack of 100
Extra Biohazard labeled zip-lock bags
with ID label for name, DOB, date of collection, for use with Microvette
No partial packs
tubes.
Each
Medium cardboard, pre-paid mailing tubes (capacity 2 samples)
Max order of 50
Each
Large cardboard, pre-paid mailing tubes (capacity 6 samples)
Max order of 50
Test Request Form:
One per order
VDHL Blood Lead Test Requisition Form (Inorg/Tox 200)
Sample Collection Instructions:
One per order
Technique for Capillary Blood Lead Sample Collection (Tox 430A)
Supply Order Form:
One per order
Order Form for Blood Lead Supplies (InorgTox 501)
* Microvette tubes expire as indicated on the container.
If you have single units and more than one year has elapsed since your last order, please replace
your capillary tube supply.
You can mail this form to the laboratory or fax to 1-802-338-4706.
InorgTox 501 Rev 2 (9/2021)
Page 1 of 1