Issue Date: 01-07-2023 Drug Requisition Form MDL-PHARM-RE-003

Effective Date: 21-07-2023 │02

Drug Profile

Generic name Strength

Brand name Dosage form
Manufacturer Route
Country of Origin Indication
Potential ADR

Cost effectiveness

Original cost of requested drug ----------------------------------------------------------

Comparison of price to the same generic

Generic 1 Generic 2 Generic 3 Generic 4 Generic 5

Name

Amount

Clinical justification for adding this drug to the formulary (open question)

-----------------------------------------------------------------------------------------------------------------------------

Reviewed by Formulary Pharmacist Only

Yes No
Legally approval by nation
Registered drug or supplement by FDA

What evidence is available to support the above claims? -----------------------------------------------------------

Monitoring requirements associated with this medicine-------------------------------------------------------------

Declaration of interest (Please specify any interests both personal and non-personal in the
product/manufacturer/supplier) -----------------------------------------------------------------------------------------
Issue Date: 01-07-2023 Drug Requisition Form MDL-PHARM-RE-003
Effective Date: 21-07-2023 │02

Requester

Name

Position

Sign

Date

If you require assistance in compiling this information, contact your pharmacist.

Please tick the relative box.

Consideration Level for approval (Filled by Medication Management Committee)

A Approved for general use - hospital and general practice.

B Approved for specialist use only.
C Approved as Prescription only medicine.
D Approved as Prescription only medicine.
E Not approved.
F No decision. Further support required.

New medicine not involved in formulary list.

New medicine with similar generic in formulary list.

Approval Signing

Position Name Date Sign

Reviewed by Secretary of MMC

Checked by Clinical
Representative of SMT

Approved by Chair or Co-chair of

MMC