{"id":3721,"date":"2020-06-23T09:28:41","date_gmt":"2020-06-22T21:28:41","guid":{"rendered":"https:\/\/www.awanuilabs.co.nz\/south\/canterbury\/?page_id=3721"},"modified":"2025-08-07T12:18:15","modified_gmt":"2025-08-07T00:18:15","slug":"medical-supplies-order-form-2","status":"publish","type":"page","link":"https:\/\/www.awanuilabs.co.nz\/south\/canterbury\/for-referrers\/medical-supplies-order-form-2\/","title":{"rendered":"Medical supplies online order form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework form-has-collapsible-sections_wrapper collapsible-sections-footer-after_last_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_11' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_11' class='form-has-collapsible-sections  collapsible-sections-footer-after_last ' action='\/south\/canterbury\/wp-json\/wp\/v2\/pages\/3721' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_11_2\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Awanui Labs provide consumables for collection of specimens for laboratory analysis only. Please note: orders may take up to 3 business days to be dispatched. <\/p><\/li><li id=\"field_11_102\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_102'>Which region are you in?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_102' id='input_11_102' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Marlborough' >Marlborough<\/option><option value='Nelson' >Nelson<\/option><option value='Christchurch \/ Canterbury' >Christchurch \/ Canterbury<\/option><option value='Timaru \/ South Canterbury' >Timaru \/ South Canterbury<\/option><option value='Otago' >Otago<\/option><option value='Southland' >Southland<\/option><\/select><\/div><\/li><li id=\"field_11_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_1'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_11_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_3'>Contact name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_11_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_93\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_93'>Contact email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_93' id='input_11_93' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_11_5\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_11_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_11_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_11_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_11_5_1' id='input_11_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_11_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_11_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_11_5_3' id='input_11_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_5.4' id='input_11_5_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_11_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_11_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_11_5_5' id='input_11_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_11_5_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_11_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Requisition forms<\/h2><\/li><li id=\"field_11_25\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_25'>Dr\/Health professional name<\/label><div class='gfield_description' id='gfield_description_11_25'>(Required for requisition form orders)<\/div><div class='ginput_container ginput_container_text'><input name='input_25' id='input_11_25' type='text' value='' class='small'  aria-describedby=\"gfield_description_11_25\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_11_103\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Requisition form type &#8211; Nelson\/Marlborough<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_103'><li class='gchoice gchoice_11_103_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.1' type='checkbox'  value='Standard tests PDF'  id='choice_11_103_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_103_1' id='label_11_103_1' class='gform-field-label gform-field-label--type-inline'>Standard tests PDF<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_103_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.2' type='checkbox'  value='Crossmatch PDF'  id='choice_11_103_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_103_2' id='label_11_103_2' class='gform-field-label gform-field-label--type-inline'>Crossmatch PDF<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_157\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Requisition form type &#8211; Otago\/Southland<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_157'><li class='gchoice gchoice_11_157_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_157.1' type='checkbox'  value='Standard tests PDF'  id='choice_11_157_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_157_1' id='label_11_157_1' class='gform-field-label gform-field-label--type-inline'>Standard tests PDF<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_157_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_157.2' type='checkbox'  value='Hospital pads'  id='choice_11_157_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_157_2' id='label_11_157_2' class='gform-field-label gform-field-label--type-inline'>Hospital pads<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_152\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_152'>Hospital requisition pads<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_152' id='input_11_152' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_152\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_152'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_158\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Requisition form type &#8211; Timaru\/South Canterbury<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_158'><li class='gchoice gchoice_11_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Standard tests PDF'  id='choice_11_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_158_1' id='label_11_158_1' class='gform-field-label gform-field-label--type-inline'>Standard tests PDF<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_156\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Requisition forms (PDFs) &#8211; Canterbury<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_156'><li class='gchoice gchoice_11_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Standard tests'  id='choice_11_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_156_1' id='label_11_156_1' class='gform-field-label gform-field-label--type-inline'>Standard tests<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_156_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.2' type='checkbox'  value='Histology PDF'  id='choice_11_156_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_156_2' id='label_11_156_2' class='gform-field-label gform-field-label--type-inline'>Histology PDF<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_156_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.3' type='checkbox'  value='Dermatology PDF'  id='choice_11_156_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_156_3' id='label_11_156_3' class='gform-field-label gform-field-label--type-inline'>Dermatology PDF<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Tubes<\/h2><\/li><li id=\"field_11_105\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_105'>Blood bank ACD tube 6mL (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_105' id='input_11_105' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_105\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_105'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_32\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_32'>Blood bank CPDA tube 9mL (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_32' id='input_11_32' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_32\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_32'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_104\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_104'>Citrate (blue) 1.8ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_104' id='input_11_104' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_104\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_104'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_92\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_92'>Citrate (blue) 2.7ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_11_92' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_92\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_92'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_159\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_159'>Citrate (blue) 3ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_159' id='input_11_159' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_159\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_159'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_106\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_106'>Citrate (blue) mini (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_106' id='input_11_106' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_106\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_106'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_35\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_35'>Crossmatch EDTA (pink) 6ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_11_35' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_35\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_35'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_40\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_40'>EDTA (lavender) 2ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_11_40' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_40\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_40'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_107\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_107'>EDTA (lavender) 3ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_107' id='input_11_107' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_107\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_107'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_108\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_108'>EDTA (lavender) 4ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_108' id='input_11_108' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_108\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_108'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_109\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_109'>EDTA (lavender) 4ml (tray\/100)<\/label><div class='ginput_container ginput_container_number'><input name='input_109' id='input_11_109' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_109\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_109'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_110\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_110'>EDTA (lavender) micro (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_110' id='input_11_110' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_110\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_110'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >ESR tube (black)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_11_170'>\n\t\t\t<li class='gchoice gchoice_11_170_0'>\n\t\t\t\t<input name='input_170' type='radio' value='(Discontinued item - Please use EDTA instead)'  id='choice_11_170_0'    \/>\n\t\t\t\t<label for='choice_11_170_0' id='label_11_170_0' class='gform-field-label gform-field-label--type-inline'>(Discontinued item &#8211; Please use EDTA instead)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_41\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_41'>Fluoride (grey) 2ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_11_41' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_41\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_41'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_160\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_160'>Fluoride (grey) 4ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_160' id='input_11_160' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_160\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_160'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_42'>Heparin (green) 2ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_11_42' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_42\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_42'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_118\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_118'>Heparin (green) 4ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_11_118' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_118\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_118'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_116\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_116'>Heparin PST (mint) 4.5ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_116' id='input_11_116' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_116\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_116'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_117\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_117'>Heparin PST (mint) micro (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_117' id='input_11_117' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_117\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_117'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_119\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_119'>Illumi (Streck) (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_119' id='input_11_119' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_119\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_119'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_43\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_43'>Plain (red) 2ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_11_43' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_43\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_43'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_122\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_122'>Plain (red) 4ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_11_122' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_122\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_122'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_138\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_138'>Plain (red) 6ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_138' id='input_11_138' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_138\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_138'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_121\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_121'>Plain (red) 10ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_121' id='input_11_121' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_121\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_121'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_111\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_111'>SST (gold) 3ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_111' id='input_11_111' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_111\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_111'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_112\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_112'>SST (gold) micro (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_112' id='input_11_112' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_112\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_112'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_94\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_94'>SST (gold) 8.5ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_11_94' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_94\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_94'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_44\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_44'>SST  (gold) 8.5ml (tray\/100)<\/label><div class='ginput_container ginput_container_number'><input name='input_44' id='input_11_44' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_44\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_44'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_36\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_36'>Trace metals &#8211; K2EDTA (navy) 6ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_11_36' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_36\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_36'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_34\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_34'>Blood culture sets &#8211; paediatric (each)<\/label><div class='gfield_description' id='gfield_description_11_34'>(Conditions apply)<\/div><div class='ginput_container ginput_container_number'><input name='input_34' id='input_11_34' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_34 gfield_description_11_34\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_34'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_113\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_113'>Blood culture bottle &#8211; aerobic (each)<\/label><div class='gfield_description' id='gfield_description_11_113'>(Conditions apply)<\/div><div class='ginput_container ginput_container_number'><input name='input_113' id='input_11_113' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_113 gfield_description_11_113\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_113'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_114\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_114'>Blood culture bottle &#8211; anaerobic (each)<\/label><div class='gfield_description' id='gfield_description_11_114'>(Conditions apply)<\/div><div class='ginput_container ginput_container_number'><input name='input_114' id='input_11_114' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_114 gfield_description_11_114\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_114'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_115\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_115'>Blood culture &#8211; bottle adaptor (each)<\/label><div class='gfield_description' id='gfield_description_11_115'>(Conditions apply)<\/div><div class='ginput_container ginput_container_number'><input name='input_115' id='input_11_115' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_115 gfield_description_11_115\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_115'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Needles<\/h2><\/li><li id=\"field_11_46\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_46'>21 gauge (green) &#8211; box\/100<\/label><div class='ginput_container ginput_container_number'><input name='input_46' id='input_11_46' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_46\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_46'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_47\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_47'>22 gauge (black) &#8211; box\\100<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_11_47' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_47\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_47'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_45\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_45'>Hubs (adult) (each &#8211; reusable)<\/label><div class='ginput_container ginput_container_number'><input name='input_45' id='input_11_45' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_45\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_45'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_123\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_123'>Hubs (adult) (pack of 5)<\/label><div class='ginput_container ginput_container_number'><input name='input_123' id='input_11_123' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_123\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_123'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_168\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_168'>Butterflies<\/label><div class='gfield_description' id='gfield_description_11_168'>(for laboratory sample collection sites only \/ limit of 5 per week)<\/div><div class='ginput_container ginput_container_number'><input name='input_168' id='input_11_168' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_168 gfield_description_11_168\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_168'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Swabs<\/h2><\/li><li id=\"field_11_50\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_50'>Chlamydia Aptima swab (orange label) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_11_50' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_50\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_50'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_52\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_52'>Chlamydia Aptima urine kit (yellow label) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_11_52' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_52\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_52'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_124\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_124'>UTM swab kit<\/label><div class='ginput_container ginput_container_number'><input name='input_124' id='input_11_124' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_124\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_124'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_53\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_53'>FLOQ orange swab<\/label><div class='ginput_container ginput_container_number'><input name='input_53' id='input_11_53' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_53\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_53'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_126\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_126'>Nasopharyngeal viral swab<\/label><div class='gfield_description' id='gfield_description_11_126'>(restricted numbers)<\/div><div class='ginput_container ginput_container_number'><input name='input_126' id='input_11_126' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_126 gfield_description_11_126\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_126'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_125\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_125'>Routine bacterial transwab (purple top) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_125' id='input_11_125' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_125\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_125'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_51\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_51'>Urethral swab<\/label><div class='ginput_container ginput_container_number'><input name='input_51' id='input_11_51' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_51\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_51'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_127\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_127'>Viral dry swab (green top) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_127' id='input_11_127' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_127\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_127'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_128\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_128'>Viral dry swab (red top) herpes &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_128' id='input_11_128' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_128\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_128'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_49\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_49'>Wire bacterial swab (orange top) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_11_49' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_49\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_49'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Specimen Collection Supplies<\/h2><\/li><li id=\"field_11_60\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_60'>Boric acid urine C&amp;S tubes (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_60' id='input_11_60' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_60\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_60'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_130\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_130'>Specimen containers &#8211; lilac (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_130' id='input_11_130' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_130\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_130'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_131\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_131'>Specimen pottles (bag of 50)<\/label><div class='ginput_container ginput_container_number'><input name='input_131' id='input_11_131' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_131\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_131'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_167\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_167'>Specimen pottles (bag of 25)<\/label><div class='ginput_container ginput_container_number'><input name='input_167' id='input_11_167' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_167\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_167'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_59\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_59'>Urine collection punnet (bag\/50)<\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_11_59' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_59\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_59'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_58\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_58'>Urine collection punnet (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_58' id='input_11_58' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_58\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_58'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_164\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_164'>Urine collection boat (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_164' id='input_11_164' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_164\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_164'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_139\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_139'>Urine collection tube (white top)<\/label><div class='ginput_container ginput_container_number'><input name='input_139' id='input_11_139' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_139\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_139'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_57\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_57'>Faeces containers with scoop (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_11_57' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_57\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_57'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_132\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_132'>Faeces containers with scoop (bag of 25)<\/label><div class='ginput_container ginput_container_number'><input name='input_132' id='input_11_132' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_132\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_132'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_56\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_56'>24-hour container (plain) &#8211; each<\/label><div class='ginput_container ginput_container_number'><input name='input_56' id='input_11_56' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_56\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_56'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_61\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_61'>Paediatric urine bags (each)<\/label><div class='gfield_description' id='gfield_description_11_61'>(conditions apply)<\/div><div class='ginput_container ginput_container_number'><input name='input_61' id='input_11_61' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_61 gfield_description_11_61\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_61'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Cytology\/Histology Supplies<\/h2><\/li><li id=\"field_11_62\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_62'>Cervex brush (25)<\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_11_62' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_62\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_62'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_66\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_66'>Cervex brush combi (50)<\/label><div class='ginput_container ginput_container_number'><input name='input_66' id='input_11_66' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_66\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_66'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_65\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_65'>Endoscan Plus (brush) (10)<\/label><div class='ginput_container ginput_container_number'><input name='input_65' id='input_11_65' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_65\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_65'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_64\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_64'>Spatula (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_64' id='input_11_64' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_64\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_64'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_133\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_133'>Spatula (10)<\/label><div class='ginput_container ginput_container_number'><input name='input_133' id='input_11_133' type='number' step='any' min='0'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_133\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_133'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/li><li id=\"field_11_63\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_63'>Surepath vials (tray of 25)<\/label><div class='ginput_container ginput_container_number'><input name='input_63' id='input_11_63' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_63\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_63'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_99\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_99'>HPV self-collect swab (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_99' id='input_11_99' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_99\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_99'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_134\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_134'>Formalin pottles 70ml<\/label><div class='ginput_container ginput_container_number'><input name='input_134' id='input_11_134' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_134\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_134'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_165\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_165'>Formalin pottles 70ml (10pk)<\/label><div class='ginput_container ginput_container_number'><input name='input_165' id='input_11_165' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_165\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_165'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_74\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_74'>Hospital only histology container 500ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_11_74' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_74\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_74'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_161\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_161'>Hospital only histology container 200ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_161' id='input_11_161' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_161\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_161'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_163\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_163'>Hospital only histology container 400ml (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_163' id='input_11_163' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_163\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_163'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_72\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_72'>Hospital only histology container 1L (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_11_72' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_72\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_72'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_75\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_75'>Hospital only histology container 2L (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_75' id='input_11_75' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_75\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_75'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_73\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_73'>Hospital only histology container 4L (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_11_73' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_73\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_73'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_162\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_162'>Hospital only histology container 10L (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_162' id='input_11_162' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_162\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_162'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_142\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Punch biopsies<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_142'><li class='gchoice gchoice_11_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='2mm'  id='choice_11_142_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_1' id='label_11_142_1' class='gform-field-label gform-field-label--type-inline'>2mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='3mm'  id='choice_11_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_2' id='label_11_142_2' class='gform-field-label gform-field-label--type-inline'>3mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_142_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.3' type='checkbox'  value='4mm'  id='choice_11_142_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_3' id='label_11_142_3' class='gform-field-label gform-field-label--type-inline'>4mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_142_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.4' type='checkbox'  value='5mm'  id='choice_11_142_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_4' id='label_11_142_4' class='gform-field-label gform-field-label--type-inline'>5mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_142_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.5' type='checkbox'  value='6mm'  id='choice_11_142_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_5' id='label_11_142_5' class='gform-field-label gform-field-label--type-inline'>6mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_142_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.6' type='checkbox'  value='8mm'  id='choice_11_142_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_142_6' id='label_11_142_6' class='gform-field-label gform-field-label--type-inline'>8mm<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_143\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Punch biopsies<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_11_143'><li class='gchoice gchoice_11_143_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.1' type='checkbox'  value='3mm'  id='choice_11_143_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_143_1' id='label_11_143_1' class='gform-field-label gform-field-label--type-inline'>3mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_143_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.2' type='checkbox'  value='4mm'  id='choice_11_143_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_143_2' id='label_11_143_2' class='gform-field-label gform-field-label--type-inline'>4mm<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_11_143_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_143.3' type='checkbox'  value='6mm'  id='choice_11_143_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_143_3' id='label_11_143_3' class='gform-field-label gform-field-label--type-inline'>6mm<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_11_146\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_146'>Punch biopsy 2mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_146' id='input_11_146' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_146\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_146'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_147\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_147'>Punch biopsy 3mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_147' id='input_11_147' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_147\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_147'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_148\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_148'>Punch biopsy 4mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_148' id='input_11_148' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_148\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_148'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_149\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_149'>Punch biopsy 5mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_149' id='input_11_149' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_149\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_149'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_150\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_150'>Punch biopsy 6mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_150' id='input_11_150' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_150\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_150'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_151'>Punch biopsy 8mm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_11_151' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_151\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_151'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Sundries<\/h2><\/li><li id=\"field_11_78\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_78'>Alcohol prep wipes<\/label><div class='gfield_description' id='gfield_description_11_78'>(for sample collection only) <\/div><div class='ginput_container ginput_container_number'><input name='input_78' id='input_11_78' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_78 gfield_description_11_78\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_78'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_81\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_81'>Blades for fungal scraping (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_81' id='input_11_81' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_81\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_81'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_82\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_82'>Glucose for GTT 75g (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_82' id='input_11_82' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_82\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_82'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_83\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_83'>Glucose for polycose 50g (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_11_83' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_83\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_83'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_80\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_80'>Plastic bag (biohazard specimen bag)<\/label><div class='ginput_container ginput_container_number'><input name='input_80' id='input_11_80' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_80\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_80'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_79\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_79'>Plastic bag &#8211; urgent (red) (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_79' id='input_11_79' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_79\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_79'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_77\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_77'>Plastic bag &#8211; INR  (blue) (each)<\/label><div class='ginput_container ginput_container_number'><input name='input_77' id='input_11_77' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_77\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_77'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_84\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_84'>Sharps 1.4L (each)<\/label><div class='gfield_description' id='gfield_description_11_84'>For laboratory sample collection only<\/div><div class='ginput_container ginput_container_number'><input name='input_84' id='input_11_84' type='number' step='any' min='1'  value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_84 gfield_description_11_84\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_84'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><\/li><li id=\"field_11_90\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-field collapsible-sections-description-title \"  data-field-class=\"collapsible-sections-field collapsible-sections-description-title\" ><h2 class=\"gsection_title\">Other<\/h2><\/li><li id=\"field_11_54\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_11_54'><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_11_54' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_11_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible collapsible-sections-end-field \"  data-field-class=\"collapsible-sections-end-field\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_11_166\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_166'>CAPTCHA<\/label><div id='input_11_166' class='ginput_container ginput_recaptcha' data-sitekey='6LcPOXAnAAAAAG292WPwvUOKXDZHFC_OO20zn0AP'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_11' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' 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