INSULIN PUMP CONSUMABLES ORDER FORM - NDSS

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Version - June 2012 NDSS Code NDSS IPC Order Form Product Description Supplier Code Supplier Catalogue No. Infusion Sets Connection Type 2 Needle cannula angle & type No. Per box 3 115 Soft Release O (6mm, 26G, 60cm) Manage S6051 Dana Proprietary sT 10 sets 15.00 116 Soft Release O (6mm, 26G, 80cm) Manage S6081 Dana Proprietary sT 10 sets 15.00 117 Soft Release O (9mm, 26G, 60cm) Manage S9051 Dana Proprietary sT 10 sets 15.00 118 Soft Release O (9mm, 26G, 80cm) Manage S9081 Dana Proprietary sT 10 sets 15.00 501 Deltec Comfort (17mm, 25G, 60cm) MSA 87-060-2652 Cozmo Luer lock aT 10 cannulae + 5 lines 12.50 502 Deltec Comfort (17mm, 25G, 80cm) MSA 87-080-2652 Cozmo Luer lock aT 10 cannulae + 5 lines 12.50 503 Deltec Comfort (17mm, 25G, 110cm) MSA 87-110-2652 Cozmo Luer lock aT 10 cannulae + 5 lines 12.50 504 Deltec Comfort (17mm, 25G, 60cm) MSA 89-060-2622 Cozmo Luer lock aT 10 sets 15.00 505 Deltec Comfort (17mm, 25G, 80cm) MSA 89-080-2622 Cozmo Luer lock aT 10 sets 15.00 506 Deltec Comfort (17mm, 25G, 110cm) MSA 89-110-2622 Cozmo Luer lock aT 10 sets 15.00 507 Cleo 90 (6mm, 28G, 61cm) MSA 21-7220-24 Generic Luer lock aT 10 sets 15.00 508 Cleo 90 (6mm, 28G, 79cm) MSA 21-7221-24 Generic Luer lock aT 10 sets 15.00 509 Cleo 90 (6mm, 28G, 107cm) MSA 21-7222-24 Generic Luer lock aT 10 sets 15.00 510 Cleo 90 (9mm, 28G, 61cm) MSA 21-7230-24 Generic Luer lock aT 10 sets 15.00 511 Cleo 90 (9mm, 28G, 79cm) MSA 21-7231-24 Generic Luer lock aT 10 sets 15.00 512 Cleo 90 (9mm, 28G, 107cm) MSA 21-7232-24 Generic Luer lock aT 10 sets 15.00 513 Accu-Chek FlexLink (8mm, 30cm) Roche 4626427001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 514 Accu-Chek FlexLink (8mm, 60cm) Roche 4626435001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 515 Accu-Chek FlexLink (8mm, 80cm) Roche 4626478001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 516 Accu-Chek FlexLink (10mm, 30cm) Roche 4626494001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 517 Accu-Chek FlexLink (10mm, 60cm) Roche 4626516001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 518 Accu-Chek FlexLink (10mm, 80cm) Roche 4626524001 Spirit/H-Tron/D-Tron Luer lock sT 10 sets 15.00 519 Accu-Chek FlexLink Cannula (8mm) Roche 4626567001 Spirit/H-Tron/D-Tron Luer lock sT 10 Cannula 10.50 520 Accu-Chek FlexLink Cannula (10mm) Roche 4626575001 Spirit/H-Tron/D-Tron Luer lock sT 10 Cannula 10.50 533 Accu-Chek TenderLink II 13/80 (13mm, 80cm) Roche 4541707001 Spirit/ D-Tron/D-Tron Plus/H-Tron Luer lock aT 20 cannulae + 10 lines 24.90 537 Inset 30 Infusion set (13mm, 110cm) grey AMSL 100-396-03 Generic Luer lock aT 10 sets 15.00 538 Inset 30 Infusion Set (13mm, 60cm) blue AMSL 100-396-01 Generic Luer lock aT 10 sets 15.00 539 Inset 30 Infusion set (13mm, 60cm) pink AMSL 100-396-02 Generic Luer lock aT 10 sets 15.00 540 Inset 30 Infusion set (13mm, 60cm) grey AMSL 100-396-00 Generic Luer lock aT 10 sets 15.00 541 Animas Comfort (17mm, 27G, 60cm) AMSL 100-006-51 Generic Luer lock aT 10 sets 15.00 542 Animas Comfort (17mm, 27G, 60cm) AMSL 100-006-03 Generic Luer lock aT 10 cannulae + 5 lines 12.50 543 Animas Comfort (17mm, 27G, 110cm) AMSL 100-006-50 Generic Luer lock aT 10 sets 15.00 544 Animas Comfort (17mm, 27G, 110cm) AMSL 100-006-02 Generic Luer lock aT 10 cannulae + 5 lines 12.50 545 Inset II - includes insertion device (6mm, 27G, 60cm) grey AMSL 100-410-00 Generic Luer lock sT 10 sets 15.00 545.1 Inset II - includes insertion device (6mm, 27G, 60cm) blue AMSL 100-410-01 Generic Luer lock sT 10 sets 15.00 545.2 Inset II - includes insertion device (6mm, 27G, 60cm) pink AMSL 100-410-02 Generic Luer lock sT 10 sets 15.00 546 Inset II - includes insertion device (9mm, 27G, 60cm) grey AMSL 100-411-00 Generic Luer lock sT 10 sets 15.00 546.1 Inset II - includes insertion device (9mm, 27G, 60cm) blue AMSL 100-411-01 Generic Luer lock sT 10 sets 15.00 546.2 Inset II - includes insertion device (9mm, 27G, 60cm) pink AMSL 100-411-02 Generic Luer lock sT 10 sets 15.00 547 Inset II - includes insertion device (6mm, 27G, 110cm) grey AMSL 100-412-00 Generic Luer lock sT 10 sets 15.00 548 Inset II - includes insertion device (9mm, 27G, 110cm) grey AMSL 100-413-00 Generic Luer lock sT 10 sets 15.00 549 Animas Comfort (60cm, 27G, 13mm) AMSL 100-240-01 Generic Luer lock aT 10 sets 15.00 551 Animas Comfort (110cm, 27G, 13mm) AMSL 100-240-03 Generic Luer lock aT 10 sets 15.00 552 Animas Comfort (60cm, 27G, 13mm) AMSL 100-240-04 Generic Luer lock aT 10 cannulae + 5 lines 12.50 553 Animas Comfort (110cm, 27G, 13mm) AMSL 100-240-05 Generic Luer lock aT 10 cannulae + 5 lines 12.50 561 Medtronic Paradigm Quickset (9mm, 25G, 110cm) Medtronic MMT-396 Paradigm Paradigm only sT 10 sets 15.00 562 Medtronic Paradigm Quickset (9mm, 25G, 60cm) Medtronic MMT-397 Paradigm Paradigm only sT 10 sets 15.00 563 Medtronic Paradigm Quickset (6mm, 25G, 110cm) Medtronic MMT-398 Paradigm Paradigm only sT 10 sets 15.00 564 Medtronic Paradigm Quickset (6mm, 25G, 60cm) Medtronic MMT-399 Paradigm Paradigm only sT 10 sets 15.00 568 Medtronic Paradigm Silhouette (17mm, 25G, 110cm) Medtronic MMT-377 Paradigm Paradigm only aT 10 sets 15.00 569 Medtronic Paradigm Silhouette (17mm, 25G, 60cm) Medtronic MMT-378 Paradigm Paradigm only aT 10 sets 15.00 576 Medtronic Quick Sets (9mm, 25G, 110cm) Medtronic MMT-390 507/507c/508 Luer lock sT 10 sets 15.00 577 Medtronic Quick Sets (9mm, 25G, 60cm) Medtronic MMT-392 507/507c/508 Luer lock sT 10 sets 15.00 578 Medtronic Quick Sets (6mm, 25G, 110cm) Medtronic MMT-391 507/507c/508 Luer lock sT 10 sets 15.00 579 Medtronic Quick Sets (6mm, 25G, 60cm) Medtronic MMT-393 507/507c/508 Luer lock sT 10 sets 15.00 582 Medtronic Silhouette (17mm, 25G, 110cm) Medtronic MMT-371 507/507c/508 Luer lock aT 10 sets 15.00 583 Medtronic Silhouette (17mm, 25G, 60cm) Medtronic MMT-373 507/507c/508 Luer lock aT 10 sets 15.00 588 Medtronic Paradigm Silhouette (13mm, 25G, 60cm) Medtronic MMT-381 Paradigm Paradigm only aT 10 sets 15.00 589 Medtronic Paradigm Silhouette (13mm, 25G, 110cm) Medtronic MMT-382 Paradigm Paradigm only aT 10 sets 15.00 590 Accu-Chek TenderLink Cannula (13mm) Roche 5015260001 H-Tron/D-Tron Luer lock aT 10 cannula 10.50 Pump 1 Price per box 4 No. Boxes $ Subtotal (A) $ Amount payable $
NDSS IPC Order Form continued NDSS Code Product Description Supplier Code Supplier Catalogue No. No. Per box 3 591 Accu-Chek TenderLink Cannula (17mm) Roche 5015251001 H-Tron/D-Tron Luer lock aT 10 cannula 10.50 592 Accu-Chek TenderLink 1 (13mm, 30cm) Roche 4541596001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 593 Accu-Chek TenderLink 1 (13mm, 60cm) Roche 4541600001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 594 Accu-Chek TenderLink 1 (13mm, 80cm) Roche 4541618001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 595 Accu-Chek TenderLink 1 (17mm, 30cm) Roche 4541634001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 596 Accu-Chek TenderLink 1 (17mm, 60cm) Roche 4541642001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 597 Accu-Chek TenderLink 1 (17mm, 80cm) Roche 4541669001 H-Tron/D-Tron Luer lock aT 10 sets 15.00 603 Soft - Release ST (19mm, 26G, 70cm) Manage SR102 Dana Dana only aT 10 sets 15.00 607 Superline Easy Release (7mm, 27G, 70cm) Manage SU313 Dana Dana only sm 10 sets 15.00 611 Superline Easy Release II (7mm, 17G, 70cm) Manage SU401 Dana Dana only sm 10 sets 15.00 615 Accu-Chek Rapid-D Link Cannula (6mm, 10cm tail) Roche 4541006001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 25 cannulae 26.30 616 Accu-Chek Rapid-D Link Cannula (8mm, 10cm tail) Roche 4541014001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 25 cannulae 26.30 617 Accu-Chek Rapid-D Link Cannula (10mm, 10cm tail) Roche 4541022001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 25 cannulae 26.30 618 Accu-Chek Rapid-D Transfer Set (28G, 20cm) Roche 4541057001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 10 lines 4.50 619 Accu-Chek Rapid-D Transfer Set (28G, 50cm) Roche 4541065001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 10 lines 4.50 620 Accu-Chek Rapid-D Transfer Set (28G, 70cm) Roche 4541073001 Spirit/ D-Tron/ D-Tron plus/H-Tron Luer lock sm 10 lines 4.50 640 Medtronic Paradigm Silhouette (13mm, 25G, 45cm) Medtronic MMT-368 Paradigm Paradigm only aT 10 sets 15.00 641 Medtronic Paradigm Silhouette (13mm, 25G, 80cm) Medtronic MMT-383 Paradigm Paradigm only aT 10 sets 15.00 642 Medtronic Paradigm Silhouette (17mm, 25G, 80cm) Medtronic MMT-384 Paradigm Paradigm only aT 10 sets 15.00 643 Medtronic Paradigm Mio (6mm, 27G, 45cm) pink Medtronic MMT-921 Paradigm Paradigm only sT 10 sets 15.00 643.1 Medtronic Paradigm Mio (6mm, 27G, 45cm) blue Medtronic MMT-941 Paradigm Paradigm only sT 10 sets 15.00 644 Medtronic Paradigm Mio (6mm, 27G, 60cm) pink Medtronic MMT-923 Paradigm Paradigm only sT 10 sets 15.00 644.1 Medtronic Paradigm Mio (6mm, 27G, 60cm) blue Medtronic MMT-943 Paradigm Paradigm only sT 10 sets 15.00 645 Medtronic Paradigm Mio (6mm, 27G, 80cm) pink Medtronic MMT-925 Paradigm Paradigm only sT 10 sets 15.00 645.1 Medtronic Paradigm Mio (6mm, 27G, 80cm) blue Medtronic MMT-945 Paradigm Paradigm only sT 10 sets 15.00 645.2 Medtronic Paradigm Mio (6mm, 27G, 80cm) clear Medtronic MMT-965 Paradigm Paradigm only sT 10 sets 15.00 646 Medtronic Paradigm Mio (9mm, 27G, 80cm) clear Medtronic MMT-975 Paradigm Paradigm only sT 10 sets 15.00 647 Medtronic Paradigm Sure - T (6mm, 29G, 60cm) Medtronic MMT-864 Paradigm Paradigm only sm 10 sets 15.00 648 Medtronic Paradigm Sure - T (8mm, 29G, 60cm) Medtronic MMT-874 Paradigm Paradigm only sm 10 sets 15.00 649 Medtronic Paradigm Sure - T (10mm, 29G, 60cm) Medtronic MMT-884 Paradigm Paradigm only sm 10 sets 15.00 650 Medtronic Paradigm Sure - T (6mm, 29G, 80cm) Medtronic MMT-866 Paradigm Paradigm only sm 10 sets 15.00 651 Medtronic Paradigm Sure - T (8mm, 29G, 80cm) Medtronic MMT-876 Paradigm Paradigm only sm 10 sets 15.00 652 Medtronic Paradigm Sure - T (10mm, 29G, 80cm) Medtronic MMT-886 Paradigm Paradigm only sm 10 sets 15.00 653 Medtronic Sure - T (6mm, 29G, 60cm) Medtronic MMT-863 507/507c/508 Luer lock sm 10 sets 15.00 654 Medtronic Sure - T (8mm, 29G, 60cm) Medtronic MMT-873 507/507c/508 Luer lock sm 10 sets 15.00 655 Medtronic Sure - T (10mm, 29G, 60cm) Medtronic MMT-883 507/507c/508 Luer lock sm 10 sets 15.00 656 Medtronic Sure - T (6mm, 29G, 80cm) Medtronic MMT-865 507/507c/508 Luer lock sm 10 sets 15.00 657 Medtronic Sure - T (8mm, 29G, 80cm) Medtronic MMT-875 507/597c/508 Luer lock sm 10 sets 15.00 658 Medtronic Sure - T (10mm,29G,80cm) Medtronic MMT-885 507/507c/508 Luer lock sm 10 sets 15.00 659 Medtronic Paradigm Quickset (6mm, 25G, 80cm) Medtronic MMT-387 Paradigm Paradigm only sT 10 sets 15.00 660 Medtronic Paradigm Quickset (9mm, 25G, 80cm) Medtronic MMT-386 Paradigm Paradigm only sT 10 sets 15.00 673 Contact Detach Infusion Set (6mm, 29G, 60cm) AMSL 100-905-00 Generic Luer lock sm 10 sets 15.00 674 Contact Detach Infusion Set (6mm, 29G, 110cm) AMSL 100-905-02 Generic Luer lock sm 10 sets 15.00 675 Contact Detach Infusion Set (8mm, 29G, 60cm) AMSL 100-905-01 Generic Luer lock sm 10 sets 15.00 676 Contact Detach Infusion Set (8mm, 29G, 110cm) AMSL 100-905-03 Generic Luer lock sm 10 sets 15.00 Pump 1 Connection Type 2 Needle cannula angle & type Price per box 4 No. Boxes $ Subtotal (B) $ Amount payable $
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INSULIN PUMP CONSUMABLES ORDER FORM - NDSS

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