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FORMULIR JAWABAN

PENGAJUAN OBAT DI LUAR FORMULARIUM

Sehubungan dengan adanya usulan permohonan obat baru (diluar formularium) di Rumah
Sakit Ibu Anak Galeri Candra:
1. Nama dagang :.......................................................................
2. Nama generic / komposisi :.....................................................................
3. Pabrik / principal :.....................................................................
4. Bentuk sediaan dan kekuatan :.....................................................................
5. Dokter pengusul :.....................................................................
6. Alasan pengusulan (berdasarkan efektifitas dan keamanan)
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Keputusan Komite Farmasi dan Terapi (diisi oleh KFT)


Disetujui
Tidak disetujui
Alasan..................................................................................................................................
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Malang,..........

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Mengetahui, Ketua Komite Farmasi Dan Terapi
Direktur RSIA Galeri Candra RSIA Galeri Candra

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