PELAYANAN INFORMASI OBAT (PIO)

APOTEK SENTOSA JAYA

Jl. Terusan bandengan Utara 95 Blok D Jakarta Utara

No : ........... Tanggal : ................. Waktu : ................. Metode : Lisan/Telp/Tertulis : .................

1. Identitas Penanya
Nama : .............................................. No. Telp : .............................
Status : Pasien / Keluarga Pasien / Petugas Kesehatan (...................................)
2. Data Pasien
Umur : ..... thn. Tinggi : ..............cm. Berat : ..........kg Jenis Kelamin : L/P
Kehamilan: Tidak/Ya, ..........minggu Menyusui : Ya/Tidak
Kasus : ..........................................................................................................................
3. Pernyataan
Uraian Pertanyaan
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Jenis Pertanyaan
Identifikasi Obat Stabilitas Farmakokinetik
Interaksi Obat Dosis Ketersediaan Obat
Harga Obat Keracunan Penggunaan Terapeutik
Kontra Indikasi ESO Lain-Lain
Cara Pemakaian
4. Jawaban
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
5. Refresensi
....................................................................................................................................................
....................................................................................................................................................
6. Penyampaian Jawaban
Segera dalam 24 Jam
Lebih dari 24 Jam
Apoteker Yang Menjawab

(.........................................)