Healthcare Infection Prevention Order Form

Please Note:

Any expedited order needs to be called in to Customer Service.
All appropriate approvals, as needed according to the policy, must be received prior to placing a no charge order.

View Ordering Guide/FAQ?

Yes

See Recently Added Items?

Yes

7/29/24 Update

6000350 - DISINFECTANT 1 FLAT PACK 7”x5.75” (12x110ea)

9/26/23 Update

6000303 - DISINFECTANT 1 FLAT PACK 9”x7” (12x72ea)

1/13/23 Update

6102290 - DAILY DISINFECTANT CLEANER 2-1.3L
6102287 - DAILY DISINFECTANT CLEANER 2.5 GAL
6102291 - DAILY DISINFECTANT CLEANER 4x1 GAL

1/13/23 Update

SIGNIFICANT CHANGES - REACH OUT TO MARKETING FOR COMPLETE LIST

8/18/21 Update

92022785 - TRAY 12.2 ENCMPS GRA

92022786 - TRAY 5.1 ENCMPS GRA

12/22/21 Update

6000256 - GNTLE CLN HND SP NX 6-750ML
6000257 - GNTLE CLN HNDSP NX 4-1250ML
6000258 - GNTLE CLN HND SOAP 6-750ML

11/8/21 Update

6000183 - E SENS SKN FM HS 12-535ML
6000185 - E-S FM AM HS 12-535ML

9/16/21 Update

EXP20604 - WH TBL STA W/NEXA COMPCT TF
6000284 - OPTIPRO MULTI-ENZYM MAN DET CONC_2.5GAL
6000285 - OPTIPRO NEUTRALIZER PLUS 1-2.5 GAL
6000286 - OPTIPRO NEUTRALIZER PLUS 4-1 GAL
6000287 - OPTIPRO MULTI-ENZYM AUTO DET UC_1-2.5GAL
6000289 - OPTIPRO NON-ENZYM MAN DET CONC 1-2.5GAL
6000290 - OPTIPRO NON-ENZYM MAN DET CONC_4-1 GAL

4/16/21 Update

822162 - SPR LIQUID GEL NAT 28/400MM
53002305 - NEXA TOUCH FREE STAND, WHITE

4/13/21 Update

92651011 - LOCKBOX 2-1/2GAL W/176 KEY

1/21/21 Update

6000263 - DISINFECT 1 SPRY 6-32 OZ
6000264 - SOLIDAIRE BLUE NF 12-14OZ
6000265 - SOLIDAIRE BLUE NF 24-7OZ
83900034 - CHGR BTRY 12V 3.5A
83900038 - A ADPTR 12V AUX PL NOCO

11/9/20 Update

6101879 - PEROX MSC & DIS RTU 6X32OZ

10/22/20 Update

53002745 - PUMPUP FMR 1.5L PP/VTN

8/31/20 Update

6102238 - ADV HAND SAN (CBC)_12-16 OZ
6102237 - ADV HAND SANIT (CBC)_4-1 GL

8/21/20 Update

6000261 - DISINFECT 1 WIPE 12-220WIPE
6000262 - DISINFECT 1 WIPE 12X85WIPES
6000270 - GEL HAND SANITIZER 12-500ML

8/19/20 Update

6000260 - OP MULTENZY DET CONC 4-1 GL

6/30/20 Update

Added the ability to easily order DAZO and CSP supplies w/ "Baseline Supplies for Field Associate" option

6/11/20 Update

6302292 - ALCOHOL ANTISEPTIC 80%_55GL
6302293 - ALCOHOL ANTISEPTIC 80%_5GL
6000271 - ALCHOL ASPTC 80% 12-500ML
6000272 - ALCOHL ANTSPTIC 80% TS_4-1G
6102220 - ALC ANTI 80% TOP SOL 4-1GAL
6600428 - GEL HAND SANIT LS 12X2 OZ

53001646 - LBL DURA USEBY2X2.25 500/RL
53002458 - RND 32OZ BTL W/FLIPTOP 12PK
92632306 - HAND PUMP 1 GAL WITH SPRING
92652354 - SPYR TRIG 9-3/8 32OZ 12PK

4/23/20 Update: Emergency WHO Products
92291327 - OAS 3 GAL PORT JUG COMPL
92002142 - WRENCH BUNG MULT-CLOS NYL
92632488 - DRUM FAUCET 3/4 BROWN PLAS
92652395 - BTL SPY 24OZ 12PK
92652352 - SPYR TRIG 7-5/8 24OZ 12PK

4/21/20 Update
53002306 - NEXA TOUCH FREE STAND, BLACK

3/5/20 Update
50000551 - BUCKETLESS MOP SYS 1PK

Account Executive Information

First Name *

Last Name *

Phone Number

Email Address *

Order Type *

Standard Order for Customer

Own Consumption for Field Associate

Baseline Supplies for Field Associate

Ship To Different Address?

Yes

Account Executive Shipping Address

Facility Name *

Employee Business Partner Number *

Cost Center *

Street Address * 🛈

Address Line 2

City *

State *

Zip Code *

Customer Shipping Information

Sold-to Number *

Customer Name: *

Contact Name

Department

PO # *

Street Address *

Address Line 2

City *

State *

Zip Code *

Request Information

Item Type: *

Chemical

Equipment

Chemical Request Information

Please Select: *

Chargeable

No Charge

No Charge Reason *

Sample/Trial

Marketing/Trade Show

Damaged Product

Defective Product

Do you know the Chemical SKU#?

Yes - Product sorted by SKU#

No - Product sorted by description

Item #1 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #2 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #3 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #4 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #5 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #6 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #7 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #8 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Equipment Request Information

Please Select: *

Chargeable

No Charge

No Charge Reason *

Do you know the Equipment (Chargeable) SKU#?

Yes - Product sorted by SKU#

No - Product sorted by description

Item #1 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #2 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #3 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #4 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #5 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #6 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #7 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Add additional item *

Yes

No

Item #8 (SKU# and Description) *

Quantity *

Apply Campaign Code?

Enter Code: Enter Code:

Please Choose: *

DAZO Supplies

CSP Supplies

DAZO Supplies (enter quantity needed)

	DAZO Ampule - 1 each (6000180)
	Blacklight - 1 each (92021207)

CSP Supplies (enter quantity needed)

	Regular Washer Process Indicator Holder - 1 each (92023642)
	Ultrasonic Washer Process Indicator Holder - 1 each (53000615)
	Washer Indicator Strips - Box of 200 (92023641)

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