PHARMACY CHARGE SLIP

Name: Age/Sex/CS: Ward/Room:

Admission Date: Admitting Physician:

□ ER fee
□ Hospital kit
□ CB-Plaster
□ VG 24
□ VG 22
□ VG 20
□ VG 18
□ Macro set
□ Micro set
□ Pillow
□ Pillow case
□ Bed sheet
□ Linen
□ CBG/HGT
□ ECG
□ Neb kit
□ Nasal cannula
□ Face mask
□ E-gloves
□ OR cap
□ 10 cc
□ 5 cc
□ 3 cc
□ TBS