Anaerobe Systems Custom Media Request

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Customer ID: 🛈

First Name *

Last Name *

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Phone Number *

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Custom Media Information

Anaerobe Systems provides pre-reduced anaerobically sterilized (PRAS) media, designed to fit your specifications. Because the media is produced and packaged in an oxygen free environment, it is optimal for the cultivation and preservation of anaerobic bacteria. With each custom media, we will guarantee that the formulation is made to the user specification, free of contamination, but can not guarantee specific performance results outside of the organisms that are tested for our quality control process.

Minimum order: The minimum order ranges between 3-4 liters of media, in which the customer is required to purchase all media produced. We will do our best to provide the requested amount +/- 10%. This works out to approximately 180 agar plates (45 packs of 4), 350 broth tubes (35 packs of 10), ten 250mL bottles, or five 500-mL bottles.

1. Media Name (subject to change) *

2. pH *

7.2 +/- 0.5

Other Other

For multiple media requests you may submit one online form with the first media, and attach the additional media requirements at the end of this form.

Provide a brief description of the media application * 🛈

3. Media Format & Quantity

	Agar media (semisolid), 100 mm plates, 4 plates per pack, 45 pack minimum order.
	Liquid media, 7 mL in Hungate capped tubes, 10 tubes per pack, 35 pack minimum order
	Liquid media, 500 mL bottles, 5 bottles minimum order.
	Liquid media, 250 mL bottles, 10 bottle minimum order
	Other - please describe above

4. Performance testing: Select 6 bacteria for quality control.

	Select up to 6 bacteria
	Growth	No Growth	Inhibited	N/A
Fusobacterium necrophorum ATCC#25286	Growth	No Growth	Inhibited	N/A
Bacteroides fragilis ATCC#25285 (standard)	Growth	No Growth	Inhibited	N/A
Clostridium perfringens ATCC#13124 (standard)	Growth	No Growth	Inhibited	N/A
Peptostreptococcus anaerobius ATCC#27337 (standard)	Growth	No Growth	Inhibited	N/A
Prevotella melaninogenica ATCC#25845 (standard)	Growth	No Growth	Inhibited	N/A
Escherichia coli ATCC#25922 (standard)	Growth	No Growth	Inhibited	N/A
Bacteroides vulgatus ATCC#8482	Growth	No Growth	Inhibited	N/A
Propionibacterium acnes ATCC#6919	Growth	No Growth	Inhibited	N/A
Clostridium difficile ATCC#9689	Growth	No Growth	Inhibited	N/A
Fusobacterium nucleatum ATCC#25586 (standard)	Growth	No Growth	Inhibited	N/A
Clostridium novyi ATCC#7659	Growth	No Growth	Inhibited	N/A
Staphylococcus aureus ATCC#25923	Growth	No Growth	Inhibited	N/A
Proteus mirabilis ATCC#12453	Growth	No Growth	Inhibited	N/A
Enterococcus faecalis ATCC#29212	Growth	No Growth	Inhibited	N/A
Other	Growth	No Growth	Inhibited	N/A

List other QC organisms, ATCC number, and expected result,

Additional QC charges:

Organisms not in stock, A.S. must obtain: ATCC organsim cost, shipping, and taxes (provide ATCC name, number, price)

5. Formulation

Provide the full media formulation in grams/L or mL/L. Do not list concentrations in molarity.
List full chemical names and composition and also include any special instructions.
Upload your media formulation in a word document or PDF.

Upload any additional reference documents.

Anaerobe Systems 15906 Concord Circle Morgan Hill, CA 95037

customerservice@anaerobesystems.com www.anaerobesystems.com
Phone: 1-800-443-3108 Fax: 408-782-3031

Doc# CS-2006a Rev 0