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LEMBAR PELAYANAN INFORMASI OBAT

NO: ...........Tgl: ............. Waktu:.......... Metode lisan/pertelp/tertulis


1. Identitas Penanya
Nama: ............................. Status: .............................
No. Telp: ...............................................
2. Data Pasien
Umur: .................... Berat: .....................kg Jenis Kelamin:L/P
Kehamilan: Ya/Tidak .................. minggu
Manyusui: Ya/Tidak Umur Bayi: ....................
3. Pertanyaan
Uraian Permohonan
..........................................................................................
..........................................................................................
Jenis Permohonan
Identifakasi Obat Dosis
Antiseptik Interaksi Obat
Stabilitas Farmakokinetik / Farmakodinamik
Kontra Indikasi Keracunan
Ketersediaan Obat Penggunaan Teraperik
Harga Obat Cara Pemakaian
ESO Lain-lain
4. Jawaban
..........................................................................................
..........................................................................................
5. Referensi
..........................................................................................
..........................................................................................
6. Penyampaian Jawaban: Segera dalam 24 jam, > 24 jam
Apoteker yang menjawab: ...............................................
Tgl: ..................... Waktu: .........................
metode Jawaban: lisan/tertulis/pertelp.

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