NBM

REQUEST FORM FOR DOCTORS REQUIREMENT

Without MSL code/visit dates of the doctor, your request cannot be approved.

Employee no. :65556 Name of field person: Yogesh Dwivedi

Designation :MT Date : 28/10/2011

FieId person's Mob. No. : 9718569756

HQ :Delhi Task force :STF

MSL code : 0 Patch no. :7

Doctor's name :Sunil Guptal Spcl/Ctg :B

Last two visits date :22/10/11 Zone : East

Current Business :4000 Practicing area of Dr. :GTB H/S

Address :3
rd
Floor,R-34,Ramesh Park,Laksmi Nagar,E.Dellhi,-92



MobiIe no. :9560118535

Requirement:
S.no. Product Quantity
1 RAMIPRES TAB tab bd
2 METOLAR XR 25 CAP 60 tab bd
3 CLOPIVAS TAB
4 ATORLIP F- TAB
5 EXERMET TAB


Requirement type: Monthly: ___yes______ SOS: __yes________
(Please write Yes/No)

S.M APPROVAL if NBM more than Rs500 :

Any speciaI comments by SM :-




0/  083.90   ..89/.943  %   .204110/507843408.9084190/4.3349-0.5574.0/   2540034    ..947 4:7706:089.

 .

0  $%  $.8147.   0/507843 84- 4   "   0   %.4/0      !..34     4. $5.20 $:3:59.947 83.9.

9     .898/.8994.90 .

 .

417 %..89    :77039:83088     !7.3.70.9. 430.

208!.82.9 ":..7 .--/  % ##!  9.8079008.399  #!#$ %  9.7  0     4-034      #06:702039 $ 34  !74/:.--/   !'$ %   % #! %   #% %    #06:702039950  439***08****** $ $**08******** !0.$  //7088  7/447 #  #.

4   $ !!# '124709..3#8   3850..4220398-$       .

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