Anda di halaman 1dari 1

KOMITE FARMASI DAN TERAPI

RUMAH SAKIT PERMATA HATI


Jl. Jendral Sudirman No.37 Duri-Riau telp (0765) 598101-595799
Email: rspermatahati@yahoo.co.id

FORM USULAN OBAT BARU

KSM :
Mohon untuk disediakan di Instalasi Farnasi Rumah Sakit Permata Hati sediaan obat
Nama Obat :
Kandungan :
Kekuatan :
Bentuk Sediaan : Injeksi / Tablet / Kapsul / Syrup / Infus
Alasan dan pertimbangan
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
..............................................................................................................................................
Duri, ………
Dokter Pemohon

(……………………………)

Anda mungkin juga menyukai