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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.: