The following form will be used when the pharmacy department wants to procure a certain medication that is not currently available in either the hospital or sister hospital if applicable!. The form is part of the main policy “Pharmacy formulary system policy” and this attachment serves as an example of the form, make sure to change the header and footer to better suit your organization design style, and add the proper dates of creation, modification and due to review date.
| HOSPITAL NAME – PHARMACY DEPARTMENT PHARMACY BORROWING FORM |
|---|
| Date: |
| To: …………………………………………………. Through: …………………………………………………. From: …………………………………………………. |
| NO. | DESCRIPTION | PACKING | QTY | PRICE |
|---|---|---|---|---|
| TOTAL PRICED | ——- |
The following items will be sent as replacement(According to your request)
| NO. | DESCRIPTION | PACKING | QTY | PRICE |
|---|---|---|---|---|
| TOTAL PRICED | ——- |
Your immediate response will be highly appreciated
Regardsj
Pharmacy supervisor
Signature / stamp:
Date:
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