AXIS-FRM-SQM.

01-015
KUALIFIKASI PELANGGAN

Nama Relasi : Tanggal Kunjungan :

Alamat Lengkap : Jam Kunjungan :

Cabang AAM : Jakarta 3

Hasil kunjungan :
1. Apakah terdapat praktek dokter di sarana relasi? Jika ya, pastikan jumlah dokter yang praktek & jadwal prakteknya
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2. Apakah terdapat RS / Klinik / Praktek dokter / Lab yang alokasinya berdekatan dengan sarana relasi?
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3. Berapa jumlah resep Psikotropika & Reguler yang masuk ke sarana per hari?
Psikotropika : ............................................................................................................................................................................
Prekursor : ............................................................................................................................................................................
Reguler : .........................................................................., Avigan :..................................................................................
4. Bagaimana kondisi daerah sekitar sarana :
 Apakah ada pemukiman?
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 Apakah ada perkantoran?
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 Apakah sarana melayani layanan antar obat ke pasien / customer?
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5. Apakah dokumen perizinan sarana kesehatan masih up date dan sesuai antara alamat pada dokumen perizinan dengan
fisik dilapangan?
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6. Bagaimana hari dan jam operasional sarana kesehatan?
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7. Apakah pemilik sarana memiliki sarana kesehatan lainnya? Jika ya, sebutkan nama sarana beserta alamat pelengkapnya
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8. Apakah sarana kesehatan memiliki Apoteker Pendamping atau Tenaga Teknis Kefarmasian (TTK)?
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9. Bagaimana jam kerja / shift kerja APJ, APING & TTK di sarana kesehatan tersebut?
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Verifikasi Hasil Kunjungan Relasi oleh Apoteker AAM :

(Jelaskan apakah hasil kunjungan ke sarana kesehatan relasi sesuai dengan kewajaran jumlah & Frekuensi Order Relasi selama ini)
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Yang melakukan kunjungan: Kacab AAM Paraf / TTD & Stempel Relasi:

(Apoteker Penanggung Jawab Sarana)

APJ Anugrah Argon Medica (Steve Nova Wibowo)
SIPA No :

No. Dokumen: AXIS-FRM-SQM.01-015 Tanggal Efektif: 1 Juli 2018

No. Rev.: 02