LIST OF KONSULTA MEDICINES

Annex A1

INSTRUCTION:
 Kindly check YES if available and NO if otherwise.
 For medicines to be outsourced to another pharmacy, please indicate in the remarks column the name of identified pharmacy and its distance from the referring facility.
Medicine Generic CODE Strength/Form/ CODE Strength/Form/
YES NO CODE YES NO CODE Medicine Generic Name Remarks
Name Volume Remarks Volume
1.6.a. Amlodipine 1.6.a.1. 10 mg Tablet (As Besilate) Name of pharmacy: 1.6.h. Fluticasone + Salmeterol 1.6.h.6. Inhalation: DPI Name of pharmacy:
___________________ 500 micrograms fluticasone (as propionate) ___________________
Distance from the referring facility + 50 micrograms salmeterol (as xinafoate) Distance from the
(in km.) x 60 doses with appropriate accompanying referring facility (in km.)
___________________ dispenser ___________________
1.6.a. Amlodipine 1.6.a.2. 5 mg Tablet (As Besilate) Name of pharmacy: 1.6.i. Gliclazide 1.6.i.1. 30 mg MR Tablet Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.b. Amoxicillin 1.6.b.1. 125 mg/5mL, 60 mL Name of pharmacy: 1.6.i. Gliclazide 1.6.i.2. 80 mg MR Tablet Name of pharmacy:
Suspension ___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.b. Amoxicillin 1.6.b.2. 250 mg/5mL, 60 mL Name of pharmacy: 1.6.j. Hydrochlorothiazide 1.6.j.1. 12.5 mg Tablet Name of pharmacy:
Suspension ___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.b. Amoxicillin 1.6.b.3. 250 mg Capsule Name of pharmacy: 1.6.j. Hydrochlorothiazide 1.6.j.2. 25 mg Tablet Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.b. Amoxicillin 1.6.b.4. 500 mg Capsule Name of pharmacy: 1.6.j. Hydrochlorothiazide 1.6.j.3 50 mg Tablet Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.b. Amoxicillin 1.6.b.5. 100 mg/mL, 10 mL Drops Name of pharmacy: 1.6.k. Losartan 1.6.k.1 50 mg Tablet (as potassium salt) Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.c. Ciprofloxacin 1.6.c.1. 250 mg Tablet (as HCI) Name of pharmacy: 1.6.k. Losartan 1.6.k.2 100 mg Tablet (as potassium salt) Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.c. Ciprofloxacin 1.6.c.2. 500 mg Tablet (as HCI) Name of pharmacy: 1.6.l. Metformin 1.6.l.1 500 mg Tablet (As Hydrochloride) Name of pharmacy:
___________________ Hydrochloride ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.d. Clarithromycin 1.6.d.1. 250 mg base Tablet Name of pharmacy: 1.6.l. Metformin 1.6.l.2 850 mg Tablet (As hydrochloride) Name of pharmacy:
___________________ Hydrochloride ___________________
 Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.d. Clarithromycin 1.6.d.2. 500 mg base Tablet Name of pharmacy: 1.6.m Metoprolol 1.6.m.1 50 mg Tablet (As Tartrate) Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.d. Clarithromycin 1.6.d.3. 500 mg MR tablet Name of pharmacy: 1.6.n. Nitrofurantoin 1.6.n.1 50 mg Capsule Name of pharmacy:
___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.d. Clarithromycin 1.6.d.4. 125 mg/5 mL granules/powder Name of pharmacy: 1.6.n. Nitrofurantoin 1.6.n.2 100 mg Capsule Name of pharmacy:
for suspension, 60 mL ___________________ ___________________
Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.e.1 250 mg amoxicillin (as Name of pharmacy: 1.6.o. Oral Rehydration Salts 1.6.o.1. 20.5 g Sachet Name of pharmacy:
(Amoxicillin + trihydrate) + 125 mg potassium ___________________ ___________________
Potassium clavulanate per tablet Distance from the referring facility Distance from the
Clavulanate) (in km.) referring facility (in km.)
___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.e.2 500 mg amoxicillin (as Name of pharmacy: 1.6.p. Paracetamol 1.6.p.1. 300 mg tablet Name of pharmacy:
(Amoxicillin + trihydrate) + 125 mg potassium ___________________ ___________________
Potassium clavulanate per tablet Distance from the referring facility Distance from the
Clavulanate) (in km.) referring facility (in km.)
___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.e.3 875 mg amoxicillin (as Name of pharmacy: 1.6.p. Paracetamol 1.6.p.2. 500 mg tablet Name of pharmacy:
(Amoxicillin + trihydrate) + 125 mg potassium ___________________ ___________________
Potassium clavulanate per tablet Distance from the referring facility Distance from the
Clavulanate) (in km.) referring facility (in km.)
___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.e.4 125 mg amoxicillin (as Name of pharmacy: 1.6.p. Paracetamol 1.6.p.3. 120 mg (125 mg)/5 mL syrup/suspension, Name of pharmacy:
(Amoxicillin + trihydrate) + 31 mg potassium ___________________ 60 mL (alcohol-free) ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
30 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.e.5 125 mg amoxicillin (as Name of pharmacy: 1.6.p. Paracetamol 1.6.p.4. 250 mg/5 mL syrup/suspension, 60 mL Name of pharmacy:
(Amoxicillin + trihydrate) + 31 mg potassium ___________________ (alcohol-free) ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
60 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.f.6. 200 mg amoxicillin (as Name of pharmacy: 1.6.p. Paracetamol 1.6.p.5. 100 mg/mL drops, 15 mL (alcohol-free) Name of pharmacy:
(Amoxicillin + trihydrate) + 28.5 mg potassium ___________________ ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
70 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.f.7. 250 mg amoxicillin (as Name of pharmacy: 1.6.q. Prednisone 1.6.q.1. 10 mg Tablet Name of pharmacy:
(Amoxicillin + trihydrate) + 62.5 mg potassium ___________________ ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
60 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.f.8. 250 mg amoxicillin (as Name of pharmacy: 1.6.q. Prednisone 1.6.q2 10 mg /5 mL, 60 mL Suspension Name of pharmacy:
(Amoxicillin + trihydrate) + 62.5 mg potassium ___________________ ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
100 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.h.9. 400 mg amoxicillin (as Name of pharmacy: 1.6.q. Prednisone 1.6.q.3 20 mg Tablet Name of pharmacy:
(Amoxicillin + trihydrate) + 57 mg potassium ___________________ ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
30 mL ___________________ ___________________
1.6.e. Co-Amoxiclav 1.6.h.1 400 mg amoxicillin (as Name of pharmacy: 1.6.q. Prednisone 1.6.q.4. 5 mg Tablet Name of pharmacy:
(Amoxicillin + 0. trihydrate) + 57 mg potassium ___________________ ___________________
Potassium clavulanate per 5 mL Distance from the referring facility Distance from the
Clavulanate) granules/powder for suspension, (in km.) referring facility (in km.)
70 mL ___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.1 400 mg sulfamethoxazole + 80 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.1. 2 mg tablet (as sulfate) Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim tablet ___________________ ___________________
Trimethoprim) Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.2 400 mg sulfamethoxazole + 80 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.2. 4 mg MR tablet (as sulfate) Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim capsule ___________________ ___________________
Trimethoprim) Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.3 800 mg sulfamethoxazole + 160 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.3. 8 mg MR tablet (as sulfate) Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim tablet ___________________ ___________________
Trimethoprim) Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.4 200 mg sulfamethoxazole + 40 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.4. 2 mg/5 mL syrup, 60 mL (as sulfate) Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ ___________________
Trimethoprim) suspension 30mL Bottle Distance from the referring facility Distance from the
(in km.) referring facility (in km.)
___________________ ___________________

1.6.f. Cotrimoxazole 1.6.f.5. 200 mg sulfamethoxazole + 40 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.5. MDI: Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ 100 micrograms/dose x 200 doses (as ___________________
Trimethoprim) suspesnsion 60 mL Bottle Distance from the referring facility (in sulfate) Distance from the
km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6f.6. 200 mg sulfamethoxazole + 40 Name of pharmacy: 1.6.r. Salbutamol 1.6.p.6 Breath-Actuated MDI (authohaler): Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ 100 micrograms/dose x 400 doses (as ___________________
Trimethoprim) suspension 70 mL Bottle Distance from the referring facility (in sulfate) Distance from the
km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.7. 200 mg sulfamethoxazole + 40 Name of pharmacy: 1.6.r. Salbutamol 1.6.p.7 Resp. Soln. (for nebulization): Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ 1 mg/mL, 2.5 mL unit dose (as sulfate) ___________________
Trimethoprim) suspension 100 mL Bottle Distance from the referring facility (in Distance from the
km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.8. 400 mg sulfamethoxazole + 80 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.8. Resp. Soln. (for nebulization): Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ 5 mg/mL, 10 mL multidose (as sulfate) ___________________
 Trimethoprim) suspension 30 mL Bottle Distance from the referring facility (in Distance from the
km.) referring facility (in km.)
___________________ ___________________
1.6.f. Cotrimoxazole 1.6.f.9. 400 mg sulfamethoxazole + 80 Name of pharmacy: 1.6.r. Salbutamol 1.6.r.9 Resp. Soln. (for nebulization): Name of pharmacy:
(Sulfamethoxazole + mg trimethoprim/5 mL ___________________ 5 mg/mL, 20 mL multidose (as sulfate) ___________________
Trimethoprim) suspension 60 mL Bottle Distance from the referring facility (in Distance from the
km.) referring facility (in km.)
___________________ ___________________
1.6.g. Enalapril 1.6.g.1. 5 mg Tablet (As Maleate) Name of pharmacy: 1.6.s. Salbutamol (as Sulfate) + 1.6.s.1. Inhalation: MDI Name of pharmacy:
___________________ Ipratropium 21 micrograms ipratropium (as bromide) + ___________________
Distance from the referring facility (in 120 micrograms salbutamol x 200 doses x Distance from the
km.) 10 mL referring facility (in km.)
___________________ ___________________
1.6.g. Enalapril 1.6.g.2. 10 mg Tablet (As Maleate) Name of pharmacy: 1.6.s. Salbutamol (as Sulfate) + 1.6.s.2. Resp. Soln. (for nebulization): Name of pharmacy:
___________________ Ipratropium 500 micrograms ipratropium (as bromide ___________________
Distance from the referring facility (in anhydrous) + 2.5 mg salbutamol (as base) x Distance from the
km.) 2.5 mL (unit dose) referring facility (in km.)
___________________ ___________________
1.6.h. Fluticasone + 1.6.h.1. Inhalation: DPI Name of pharmacy: 1.6.t. Simvastatin 1.6.t.3. 10 mg Tablet Name of pharmacy:
Salmeterol 100 micrograms fluticasone (as ___________________ ___________________
propionate) + 50 micrograms Distance from the referring facility (in Distance from the
salmeterol (as xinafoate) x 28 km.) referring facility (in km.)
doses with appropriate ___________________
accompanying dispenser ___________________
1.6.h. Fluticasone + 1.6.h.2. Inhalation: DPI Name of pharmacy: 1.6.t. Simvastatin 1.6.t.4. 20 mg Tablet Name of pharmacy:
Salmeterol 100 micrograms fluticasone (as ___________________ ___________________
propionate) + 50 micrograms Distance from the referring facility (in Distance from the
salmeterol (as xinafoate) x 60 km.) referring facility (in km.)
doses with appropriate ___________________
accompanying dispenser ___________________
1.6.h. Fluticasone + 1.6.h.3. Inhalation: DPI Name of pharmacy: 1.6.t. Simvastatin 1.6.t.1. 40 mg Tablet Name of pharmacy:
Salmeterol 250 micrograms fluticasone (as ___________________ ___________________
propionate) + 50 micrograms Distance from the referring facility (in Distance from the
salmeterol (as xinafoate) x 28 km.) referring facility (in km.)
doses and with appropriate ___________________ ___________________
accompanying dispenser

1.6.h. Fluticasone + 1.6.h.4. Inhalation: DPI
Salmeterol 250 micrograms fluticasone (as
propionate) + 50 micrograms
salmeterol (as xinafoate) x 60
doses with appropriate
accompanying dispenser
1.6.h. Fluticasone + 1.6.h.5. Inhalation: DPI
Salmeterol 500 micrograms fluticasone (as
propionate) + 50 micrograms
salmeterol (as xinafoate) x 28
doses with appropriate
accompanying dispenser
Name of pharmacy: 1.6.t. Simvastatin 1.6.t.2. 80 mg Tablet Name of pharmacy:
___________________ ___________________
Distance from the referring facility (in Distance from the
km.) referring facility (in km.)
___________________
___________________
Name of pharmacy:
__________________ PREPARED BY: CERTIFIED BY:
Distance from the referring facility (in ______________________________ ____________________________
km.) Designation Head/Owner
__________________ Signature over Printed Name Signature over Printed Name
Date Signed: ____________________ Date Signed: __________________