Patient’s Detail
Patient Name: (i) Case No.: (i)
(ii) (ii)
Details of Drug
Name of Drug: Generic Trade
Manufacturer: Registered drug: [PCU Row R or S]
Dosage Form and Strength:
Unit Cost (HK$):
Diagnosis/
Indication for use:		 Licensed indication:

Licensed Indication(s) in HK: (i)
(ii)
Dosage: Licensed dose:

 Intended duration of treatment:
Total quantity required and estimated cost:

HK$ [calculate above value * [PCU Row O]]
Justification for use:



Rationale for request: (Benefits over formulary drug)
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Funding of treatment:


Note 1: (a) preliminary clinical evidence only, (b) marginal clinical benefits over alternatives at significant higher cost, or (c) life- style drugs.
Note 2: (a) Emergency and immediate life-threatening, (b) Antidotes, or (c) Treatment of infectious disease
Requesting Doctor
Signature:
Name (BLOCK LETTERS):
Rank and Specialty:
Date:
Endorsement by Department COS
Signature:
Name (BLOCK LETTERS):
Rank and Specialty:
Date:
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Drug Monograph
Item code
Drug name
Trade name
Form description
Strength
HA Formulary status
Unit Cost
Therapeutic classification
Warnings
Dosing information
Dose in Renal Impairment
Information adapted from the Renal Drug Database: https://renaldrugdatabase.com

Product inserts and related documents
Link Document type Title Trade name Manufacturer Version date
Other information
Nil.