Formulir Pengurangan Atau Penambahan Obat

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FORMULIR PENGURANGAN ATAU PENAMBAHAN OBAT

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FORMULIR PENAMBAHAN DAN PENGURANGAN OBAT

DALAM FORMULARIUM
PUSAT LAYANAN KESEHATAN
UNIVERSITAS AIRLANGGA
Penambahan / Pengurangan *)

Nama obat Kekuatan Farmakologi & Harga Ket. Lain

indikasi

Tambahan :
Alasan mengapa obat di ajukan untuk ditambah / dihapuskan …………………………………………………
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Penjelasan bukti ilmiah obat

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Surabaya ,
Mengetahui Menyetujui

Apoteker penanggung jawab Ketua PLK Unair

Rossa patria nanda Bu erna
NIP . 199411102020013201

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