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Employee Portal

Health Services Supply Request Form

This form is typically utilized by Residential, ALS, Avenue A, and Avenue B. Medical Supplies are fulfilled by the Health Services Team. Please be sure to complete the form in it’s entirety.

Should you have any problems with this form, please contact Lacey Mills or Tasha Miller.

Name(Required)

Items Requested

Briefs - Tabs (Comes in Packages of 20-50 Based on Size or a Case of 4 Packages)

These briefs include the tabs on the side and are not a pull up brief.

Briefs - Pull Ups (Comes in Packages of 20-50 Based on Size or a Case of 4 Packages)

These briefs are the pull up briefs and do not have tabs on the side.

Underpads/Chux (Comes in a Case of 6 packages that have 25 underpads each))

These are used on chairs and beds.

Gloves (Comes in boxes of 100 OR a Case of 10 boxes of 100)

Wipes (Comes in Case of 12 packages with 64 wipes each)

Med Cups (Comes in Sleeve of 50)

Narcotic Medication Administration/Count Sheets

Peer Review Forms

Other Items