4495-97E (2017/10) Queen's Printer for Ontario, 2017 Disponible en franais 7530-5039-E

Ministry of Health and Long-Term Care

Ontario Government Pharmaceutical and Medical Supply Service Tel. 416 327-0837 Fax 416 327-0818

OGPMSS Requisition for Medical Supplies Ministry Use Only

Order Number

Instructions Complete the Ship to information and the Quantity ordered column in its entirety.

Fax your order to OGPMSS at 416 327-0818. Note: Please refer to the transport schedule for order deadlines to meet the next scheduled delivery for your zone.

Ship to AddressClient Name Client No.

Unit No. Street No. Street Name Telephone No.

City Province Postal Code Fax No.

Date ordered (yyyy/mm/dd) Ordered By Requisitioner Signature

Authorized Person's Name (please print) Authorized Person's Signature

Product No. Quantity Ordered (units) Units Description

Cups6530-1950-1 X Carton/1000 Cold drink, paper, waxed/poly-coated, Leak-proof, 5 oz.6530-1902-1 X Carton/5000 Medicine, plastic, graduated, 30mL6530-1951-0 X Carton/5000 Portion, paper, pleated, 15mL6530-1952-0 X Carton/5000 Portion, paper, pleated, 30mL6530-1954-0 X Carton/5000 Portion, paper, pleated, 96mL

Diagnostic Agents6536-0838-0 X Bottle/100 strips Chemstrip 5 (urine strip)

Dressings 6510-2228-0 X Package/50 Wound, transparent, adhesive film, sterile, 10cm x 12cm

Gloves6515-2068-0 X Box/100 Nitrile, powder free, X-Large6515-2067-0 X Box/100 Nitrile, powder free, Large6515-2066-0 X Box/100 Nitrile, powder free, Medium6515-2065-0 X Box/100 Nitrile, powder free, Small6515-1913-0 X Box/100 Vinyl, examination, pre-powdered, Large

Sharps Collectors7240-0019-0 X Each/1 Sharps collector 1 litre (+ or 250mL)7240-0021-0 X Each/1 Sharps collector 3 litre (+ or 500mL)7240-0018-1 X Each/1 Sharps collector 7.6 litre (+ or 1L)7240-0018-0 X Each/1 Sharps collector 10.3 litre (+ or 1L)

Needles6515-2063-0 X Box/100 Safety-engineered Insulin Pen Needle, 29g x 8mm or 30g x 8mm size

Personal Care6510-1913-2 X Package/200 Alcohol swabs, Isopropyl Alcohol 70% 8520-0017-0 X Bottle/114mL Hand sanitizer, ethyl alcohol 8520-0018-0 X Bottle/540mL Hand sanitizer, ethyl alcohol 6502-1504-2 X Case/36 Mouthwash alcohol free 115mL 6576-1706-1 X Bottle/237mL Sun protective lotion SPF 60 8530-1904-0 X Box/250 Swabstick (for oral care) 8105-0070-0 X Case/30 boxes Tissue, facial, disposable, white, 2 ply, 21cm x 22.5cm 8105-0080-0 X Case/48 rolls Tissue, toilet, white, 2 ply, 10.5cm x 11cm 8530-1907-0 X Package/100 Toothbrush, adult 8520-1901-5 X Case/24 Toothpaste, fluoride, 18 ml tube6529-2006-2 X Bag/76 Washcloth, disposable, white 31.25cm x 25cm

Trays6515-1950-2 X Case/16 Catheterization Tray, disposable 6510-2301-0 X Case/20 Dressing Tray, disposable 5 item

Forms

7530-5039-E OGPMSS Requisition for Medical Supplies (Form No. 4495-97E). Form available online at http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/ (form#4495-97E)

OtherXXX

http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=4495-97E&NO=014-4495-97Ehttp://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=4495-97E&NO=014-4495-97E

OGPMSS Requisition for Medical Supplies

4495-97E (2017/10) Queen's Printer for Ontario, 2017

Disponible en franais

Disponible en franais

7530-5039-E

OGPMSS Requisition for Medical Supplies

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Government of Ontario

Ministry of Healthand Long-Term Care

Ontario Government Pharmaceuticaland Medical Supply ServiceTel. 416 327-0837Fax 416 327-0818

OGPMSS Requisition for Medical Supplies

Ministry Use Only

Order Number

Instructions

Complete the Ship to information and the Quantity ordered column in its entirety.

Fax your order to OGPMSS at416 327-0818.Note: Please refer to the transport schedule for order deadlines to meet the next scheduled delivery for your zone.

Ship to Address

Product No.

Quantity Ordered(units)

Units

Description

Cups

6530-1950-1

Carton/1000

Cold drink, paper, waxed/poly-coated, Leak-proof, 5 oz.

6530-1902-1

Carton/5000

Medicine, plastic, graduated, 30mL

6530-1951-0

Carton/5000

Portion, paper, pleated, 15mL

6530-1952-0

Carton/5000

Portion, paper, pleated, 30mL

6530-1954-0

Carton/5000

Portion, paper, pleated, 96mL

Diagnostic Agents

6536-0838-0

Bottle/100 strips

Chemstrip 5 (urine strip)

Dressings

6510-2228-0

Package/50

Wound, transparent, adhesive film, sterile, 10cm x 12cm

Gloves

6515-2068-0

Box/100

Nitrile, powder free, X-Large

6515-2067-0

Box/100

Nitrile, powder free, Large

6515-2066-0

Box/100

Nitrile, powder free, Medium

6515-2065-0

Box/100

Nitrile, powder free, Small

6515-1913-0

Box/100

Vinyl, examination, pre-powdered, Large

Sharps Collectors

7240-0019-0

Each/1

Sharps collector 1 litre (+ or 250mL)

7240-0021-0

Each/1

Sharps collector 3 litre (+ or 500mL)

7240-0018-1

Each/1

Sharps collector 7.6 litre (+ or 1L)

7240-0018-0

Each/1

Sharps collector 10.3 litre (+ or 1L)

Needles

6515-2063-0

Box/100

Safety-engineered Insulin Pen Needle, 29g x 8mm or 30g x 8mm size

Personal Care

6510-1913-2

Package/200

Alcohol swabs, Isopropyl Alcohol 70%

8520-0017-0

Bottle/114mL

Hand sanitizer, ethyl alcohol

8520-0018-0

Bottle/540mL

Hand sanitizer, ethyl alcohol

6502-1504-2

Case/36

Mouthwash alcohol free 115mL

6576-1706-1

Bottle/237mL

Sun protective lotion SPF 60

8530-1904-0

Box/250

Swabstick (for oral care)

8105-0070-0

Case/30 boxes

Tissue, facial, disposable, white, 2 ply, 21cm x 22.5cm

8105-0080-0

Case/48 rolls

Tissue, toilet, white, 2 ply, 10.5cm x 11cm

8530-1907-0

Package/100

Toothbrush, adult

8520-1901-5

Case/24

Toothpaste, fluoride, 18 ml tube

6529-2006-2

Bag/76

Washcloth, disposable, white 31.25cm x 25cm

Trays

6515-1950-2

Case/16

Catheterization Tray, disposable

6510-2301-0

Case/20

Dressing Tray, disposable 5 item

Forms

7530-5039-E

OGPMSS Requisition for Medical Supplies (Form No. 4495-97E). Form available online at

http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/ (form#4495-97E)

Other

8.0.1291.1.339988.308172

Ministry of Health and Long-Term Care

OGPMSS Requisition for Medical Supplies

Ministry of Health and Long-Term Care

OGPMSS Requisition for Medical Supplies

Print Form: Clear Form: TextField1: Ship to Address. Client Name.: Ship to Address. Client Number.: Ship to Address. Unit Number.: Ship to Address. Street Number.: Ship to Address. Street Name.: Telephone Number.: Ship to Address. City.: Ship to Address. Province.: Ship to Address. Enter Postal Code in format: letter, digit, letter, digit, letter, digit.: Fax Number.: Date Ordered. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar.: Ship to Address. Ordered by.: Requisitioner Signature:: Authorized Person's Name (please print).: Authorized Person's Signature.: Other. Item 3. Description.: