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  • Proforma E

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    Suhaimi Mohd Isa
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    The form requests details of the non-standard drug needed such as its generic name, cost and substitute drugs available. It must be completed by the proposing medical officer and reviewed by the Facility Management Section and Drug Committee for final approval or denial. The Drug Committee will determine the approved quantity if the request is approved.

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    The form requests details of the non-standard drug needed such as its generic name, cost and substitute drugs available. It must be completed by the proposing medical officer and reviewed by the Facility Management Section and Drug Committee for final approval or denial. The Drug Committee will determine the approved quantity if the request is approved.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    18 views2 pages

    Proforma E

    Uploaded by

    Suhaimi Mohd Isa
    The form requests details of the non-standard drug needed such as its generic name, cost and substitute drugs available. It must be completed by the proposing medical officer and reviewed by the Facility Management Section and Drug Committee for final approval or denial. The Drug Committee will determine the approved quantity if the request is approved.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Proforma E

    Borang Permohonan Untuk Pembelian Ubat Bukan Standard


    (Request for Procurement of Non-Standard Drugs)
    Klinik Kesihatan Melaka Tengah
    ________________________________________________________________________

    A. DETAILS OF DRUG REQUESTED


    1. Generic Name: _____________________________________________________
    2. MOH List No: _____________________________________________________
    3. Category of Drug: A / A* / A/KK / B / C
    4. Estimated Number of Patients/Cases (please specify annually, monthly or daily)
    ____________________________________________________________________
    5. Unit/Annual Cost: __________________________________________________
    6. Substitute(s) Available: ______________________________________________
    7. Reason Why Substitute(s) Available Cannot be Used:
    __________________________________________________________________________
    __________________________________________________________________________

    Proposed by:
    ____________________________
    Name: ______________________
    Chop: ______________________
    Date: ______________________

    B. COMMENTS BY FMS (mandatory for requests from Medical Officers, other than FMS)
    ______________________________________________________________________
    ______________________________________________________________________
    ______________________________________________________________________

    _________________________
    Name: ______________________
    Chop: ______________________
    Date: ______________________

    C. APPROVAL STATEMENT BY DRUG COMMITTEE


    (i) Approved / Not Approved
    (ii) Quantity Approved : ______________________________

    Date: _____________ _____________________________


    Pegawai Kesihatan Daerah
    Pengerusi Mesyuarat J/K Ubat-ubatan
    Daerah Melaka Tengah

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