‫طلب إتالف أدوية‬

DHA-MDR-2016-0000- Medications Disposal Form

Time: HH : MM AM :‫الوقت‬ Date: :‫التاريخ‬
‫اسم‬
Facility name:
:‫المنشأة‬
Pharmacist in-charge name: :‫اسم الصيدلي المسؤول‬

Pharmacist in-charge license No: :‫رقم ترخيص الصيدلي المسؤول‬

Facility license No: : ‫ رﻗم ﺗرﺧﯾص اﻟﻣﻧﺷﺄة‬Telephone: :‫الهاتف‬

Location: :‫اﻟﻣوﻗﻊ‬ Email: :‫البريد اإللكتروني‬

Below medications will be disposed for the following reason(s) ‫سيتم إتالف أصناف األدوية المذكورة أدناه وذلك لألسباب اآلتية‬
‫أدوﯾﺔ ﺣﻛوﻣﯾﺔ‬ ☐ ‫ﻏﯾر ﻣﺳﺟﻠﺔ ﺑوزارة اﻟﺻﺣﺔ‬ ☐ ‫اﻧﺗﮭﺎء ﺗﺎرﯾﺦ اﻟﺻﻼﺣﯾﺔ‬ ☐
Governmental medications Non registered in MOH Expired medication
‫ﺗﺎﻟﻔﮫ‬ ‫ﻋﯾﻧﺎت ﻣﺟﺎﻧﯾﺔ ﻏﯾرﻣﻌدة ﻟﻠﺑﯾﻊ‬ ☐ ‫ﻻ ﯾوﺟد ﺗﺎرﯾﺦ ﺻﻼﺣﯾﺔ‬ ☐
Damaged Free samples not for sale No expiry date
‫ﻣﻣﻧوع ﺗداوﻟﮭﺎ ﺑﺎﻟدوﻟﺔ‬ ☐ ‫ﻣﺣﻔوظﺔ ﺧﺎرج اﻟﺛﻼﺟﺔ‬ ☐ ‫ﻏﯾر ﻣﺳﻌرة ﻣن ﻗﺑل وزارة اﻟﺻﺣﺔ‬ ☐
Prohibited to be traded in UAE Stored outside refrigerator Not priced by MOH
‫أﺳﺑﺎب أﺧرى‬ ☐ ‫ﯾوﺟد ﺗﻐﯾرات ﻓﯾزﯾﺎﺋﯾﺔ‬ ☐ ‫ﻏﯾر ﻣطﺎﺑﻘﺔ ﻟﺗﺳﻌﯾرة وزارة اﻟﺻﺣﺔ‬ ☐
Other reasons Physically changed Not compatible with MOH price list
Notes: :‫مالحظات‬

‫اﺳم اﻟﻣﻧﺗﺞ‬ ‫اﻟﺗرﻛﯾز‬ ‫اﻟﺷﻛل اﻟﺻﯾدﻻﻧﻲ‬ ‫اﻟﻛﻣﯾﺔ‬ ‫رﻗم اﻟﺗﺷﻐﯾل‬ ‫ﺗﺎرﯾﺦ اﻧﺗﮭﺎء اﻟﺻﻼﺣﯾﺔ‬
Product name Concentration Dosage form Quantity Batch number Expiry date
1

2 DD/MM/YYYY

3 DD/MM/YYYY

4 DD/MM/YYYY

5 DD/MM/YYYY

6 DD/MM/YYYY

7 DD/MM/YYYY

8 DD/MM/YYYY

9 DD/MM/YYYY

10 DD/MM/YYYY

‫رﺋﯾس ﻗﺳم اﻟرﻗﺎﺑﺔ اﻟدواﺋﯾﺔ‬ ‫اﻟﻣﻔﺗش اﻟﺻﺣﻲ‬ ‫المدير الطبي‬/‫الصيدلي المسؤول‬

Head of Drug Control Health Inspector Pharmacist in-charge/Medical Director
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Submit the Medication Disposal Certificate to DCS within One Month and keep copy in the pharmacy.