This form will be used when the user; either a physician or a pharmacist is requesting a specific drug to be added to the pharmacy formulary. 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 AND THERAPEUTICS COMMITTEE REQUEST FOR ADDITION OF NEW DRUG TO THE FORMULARY |
|---|
| Generic name: |
| Trade name: |
| Dosage form: Strength: |
| Manufacturer: |
| Pharmacological classification: |
| Therapeutic use(s): |
| Are there any alternatives drugs In the hospital formulary? (NO) – (YES) Please mentioned all: |
| What are the current drugs in the formulary could be replaced? |
| How is this drug compared to the existing current formulary drugs in terms of: 1) Therapeutic efficacy: 2) Safety: 3) Cast effectiveness: 4) Adverse effect: |
| What will be the estimated three months use rate if this drug added to the formulary: |
| Requested by: | Signature: |
| Specialty: | Date: |
| Department head: | Signature: |
| Medical Director: | Signature: |
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