FORMULIR PERMINTAAN OBAT BARU

DILUAR STANDARISASI OBAT RUMAH SAKIT PENGAYOMAN

1. Nama Generik :..................................................................................................

2. Nama dagang dan pabrik :..................................................................................................
3. Nama pasien :..................................................................................................
4. Indikasi :..................................................................................................
5. Jumlah yang diminta :..................................................................................................
6. Alasan permintaan :...................................................................................................
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Nunukan,......................................
Dokter Yang meminta,

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NIP...................................................

Rekomendasi Komite Farmasi dan Terapi :

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Nunukan, ..............................2019
Ketua KFT

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NIP..................................

Menyetujui,

Kepala Komite Medik Direktur Rumah Sakit

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NIP................................................ NIP......................................................