Nama Gol sat kandungan kekuatan
ACTIFED PLUS COUGH SUPRESSANT 60ML PR BP PSEUDOEFEDRINE HCL SYR&30MG
ACTIFED PLUS EXPECTORANT 60 ML HIJAU PR BP PSEUDOEFEDRINE HCL SYR/30MG
ACTIFED SYR 60 ML KUNING PR BP PSEUDOEFEDRINE HCL SYR&30MG
ALLERIN EXPECT 60 ML PR FLS PSEUDOEPHEDRINE syr/15MG
ALPARA KAPLET PR BOX PHENYLPROPANOLAMIN HCL KAP/12.5MG
ALPARA SIRUP PR FLS PHENYLPROPANOLAMAIN HCL SYR 3.75MG
ANACETINE PLUS SYR 60ML PR BTL PHENYLPROPANOLAMINE HCI SYR/3.5MG
ANAKONIDIN OBH 30 ML PR FLS PSEUDOEPHEDRINE SYR 7.5 MG
ANAKONIDIN OBH 60 ML PR FLS PSEUDOEPHEDRINE SYR 7.5 MG
ANAKONIDIN SYRUP 30 ML PR FLS PSEUDOEFEDRIN HCL SYR,7.5MG
ANAKONIDIN SYRUP 60ML PR BTL PSEUDOEFEDRINE HCL SYR7.5MG
ANATON CAP 100 PR BOX PHENYLPROPANOLAMIN HCL KAP/12.5MG
ANATON SYR 60 ML PR BTL PHENYLPROPANOLAMIN SYR 3.5MG
ASMASOLON 25X4 PR BOX EFEDRINE TAB,12.5MG
ASTHMA SOHO KAPLET 25X4 PR BOX EFEDRINE HCL KAP/12.5MG
BETAFLU 60 ML PR FLS EFEDRINE HCL SYR/2MG
BODREX BATUK DOUBLE ACTION SYR 60ML OOT FLS DEXTROMETHORPHAN SYR 15MG
BODREX FLU&BTK PE /KAP 4'S BLISTER OOT BLS DEXTROMTHORPHAN HBR KAP/12MG
BODREX FLU&BTK PE/KAP 4'S BLS OOT BOX DEXTROMTHORPHAN HBR KAP/12MG
BODREX FLU&BTK PE/SYR 60ML OOT BTL DEXTROMETHORPHAN HBR SYR/4MG
BROCHIFAR 10X10 KPL IFAR PR BOX PHENYLPROPANOLAMIN HCL KAP/15MG
BROCHIFAR PLUS 10X10 KPL PR BOX PHENYLPROPANOLAMIN HCL KAP/15MG
BROCON KAP 10X10 IFAR OOT BOX DEXTROMETHORPHAN HBR KAP/10MG
BRONCHITIN FLU 60 ML PR BTL PSEUDOEFEDRINE HCL SYR 15MG
BUFAGAN SYR PR FLS EPHEDRINE HCI 2,5 MG/5ML
BUFAKRIS SYR PR FLS EFEDRINE HCL SYR/4,17MG
CALORTUSIN KAPLET 10X10 PR BOX PHENYLPROPANOLAMINE HCL KAP/15MG
CALORTUSIN SYR PR FLS PHENYLPROPANOLAMIN HCL SYR/3.75MG
CITOCETIN SYR PR FLS PSEUDOEFEDRINE HCL SYR,7.5MG
COLFIN KAP PR BOX PHENYLPROPANOLAMINE KAP 15 MG
COLFIN PLUS SYR PR FLS PHENYLPROPANOLAMINE SYR 2.5 MG
COLFIN SYR OOT FLS DEXTROMETHORPAN SYR 5 MG
COPARCETIN KAPLET 10X10 PR BOX PSEUDOEFEDRINE HCL KAP/30MG
COPARCETIN SYR 60ML PR FLS EFEDRINE HCL SYR/4MG
DECOLGEN LIQ 60 ML * PR FLS PSEUDOEFEDRIN HCL SYR,7.5MG
DECOLGEN TAB 25X4 * PR BOX PHENYLPROPANOLAMINE HCL TAB/12.5MG
DECOLSIN KAPSUL PR BOX PSEUDOEFEDRINE HCL KAPSUL ,30mg
DECOLSIN SYR 60 ML * PR FLS PSEUDOEFEDRINE HCL SYR 15MG
DECOTAN 10X10 KPL IFAR PR BOX PHENYLPROPANOLAMINE HYDROCHLORKAP/15MG
DECOTAN KAPLET PR BOX PHENYLPROPANOLAMIN KAP/15MG
DEMACOLIN SYR 60ML PR FLS PSEUDOEFEDRINE HCL SYR/7.5MG
DEMACOLIN TAB 10X10 PR BOX PSEUDOEFEDRIN HCL TAB/7.5MG
DEVOSIX DROPS 15 ML IFAR PR FLS PSEUDOEPHEDRIN HCL SYR/7.5MG
DEXTRAL KAPLET PR BOX PHENYLPROPANOLAMIN HCL KAP 12.5MG
DEXTRAL SYRUP 60ML PR BTL PHENYLPROPANOLAMIN HCL SYR/12.5MG
DEXYL.SYR OOT FLS DEXTROMETHORPAN 12MG
ELSIRON 10X10 KPL IFAR PR BOX PHENYLPROPANOLAMIN HCL KAP/15MG
ERLAFLU SYRUP PR FLS PSEUDOEFEDRINE SYR 7.5 MG
ERPHAFLU SYR 60 ML PR BTL PHENYLPROPAMOLAMIN HCL SYR/3.5MG
ERPHAKAF TAB @100TAB PR BOX PHENYLPROPANOLAMIN HCL TAB10MG
ETAFLUSIN SIRUP PR FLS EPHEDRINE HCL SYR 3MG
FARNIREX 10X10 KPL IFAR PR BOX PHENYLPROPANOLAMIN HCL KAPLET/15MG
FLUANZA KAPLET 10X10 PR BOX PHENYLPROPANOLAMIN HCL KPT 12,5MG
FLUANZA SYR 60ML PR BTL PHENYLPROPANOLAMIN HCL SYR.3.125MG
FLUCADEX KAPLET 10X10 PR BOX PHENYLPROPANOLAMIN KAP/15MG
FLUCADEX PE KAPLET OOT BOX DEXTROMETHORPHAN KAP,15MG
FLUCADEX PE SYR OOT FLS DEXTROMETHORPHAN SYR 7.5MG
FLUCADEX SYR PR BTL PHENYLPROPANOLAMIN SYR/7.5MG
FLUMIN KAP BOX PR BOX PHENYLPROPANOLAMIN KAP 15MG
FLUMIN KAPLET '100 JAR PR BP PHENYLPROPANOLAMIN HCL KAP/15MG
FLUMIN PLUS SYR 60ML PR FLS PHENYLPROPANOLAMINE HCL SYR 3.5MG
FLUNADIN 10X10 KPL IFAR PR BOX PSEUDOEPHEDRIN HCL TAB/30MG
FLUNAX KAPTAB 10X10 PR BOX PHENYLPROPANOLAMIN HCL KAP,15MG
FLUNAX SYR 60ML PR BTL PHENYLPROPANOLAMIN HCL SYR,3.5MG
FLUTAMOL KAPLET '100 PR BOX PHENYLPROPANOLAMIN KAP/15MG
FLUTAMOL SYRUP PR FLS PHENYLPROPANOLAMIN HCL SYR/3.5MG
FLUTOP C SYRUP 60 ML IFAR PR FLS PHENYLPROPANOLAMIN HCL SYR/3.5MG
FLUTROP KAPL 100'S PR BOX PSEUDOEPHEDRINE HYDROCHLORIDE|TR
KAPLET 30MG
FLUTROP SYR 60ML PR FLS PSEUDOEFEDRINE SYR 15MG
GRANTUSIF KAPLET OOT BOX DEXTROMETHORPHAN KAP&15MG
HUFAGRIP FLU&BATUK 60 ML KUNING PR FLS PSEUDOEFEDRINE HCL SUSP&7.5MG
HUFAGRIP FORTE KAP 10X10 PR BOX PSEUDOEFEDRINE HCL KAP/30MG
HUFAGRIP PILEK SYR BIRU PR FLS PSEUDOEFEDRINE HCL SYR&15MG
HUFAGRIP SYR BP 60 ML DEWASA PR FLS PSEUDOEFEDRINE HCL SYR,30MG
HUFAGRIP SYR BP 60 ML HIJAU PR FLS PSEUDOEFEDRINE HCL SYR&15MG
HUFAGRIP XS KAPLET PR BOX PHENYLPROPANOLAMIN KAP&15 MG
HUSTAREX SYR OOT FLS DEXTROMETORPHAN 10MG/5ML
IAFED SYRUP 60ML PR FLS PSEUDOEFEDRINE HCL SYR,30MG
IAFED TABLET 10X10 PR BOX PSEUDOEFEDRINE HCL TAB,30MG
IFARSYL KAPLET 100'S OOT BOX DEXTROMETHORPHAN KAP/15MG
IFARSYL PLUS SYRUP 60ML IFAR OOT FLS DEXTROMETHORPHAN HBR SYR/10 MG
INTUNAL 100 CAPLET PR BOX PHENYLPROPANOLAMIN HCL TAB/3.5MG
INTUNAL F 25X4 PR BOX PHENYLPROPANOLAMIN HCL TAB/15MG
INTUNAL SYR 60 ML PR FLS PHENYLPROPANOLAMIN HCL SYR/3.5MG
INZA KAPLET 25X4 PR BOX PSEUDOEFEDRIN HCL KAP/30MG
KOMIX JAHE SACHET 30X@7ML OOT BOX DEXTROMETHORPHAN SYR/15MG
KOMIX JERUK NIPIS SACHET 30*@7ML OOT BOX DEXTROMETHORPHAN SYR/ 15 MG
KOMIX KID STRAWBERY SACHET 10SCHTX@5MLOOT BOX DEXTROMETHORPHAN syr/7.5mg
KOMIX PEPPERMINT SACHET 30*7ML OOT BOX DEXTROMETHORPHAN SYR /15 MG
KONIDIN TABLET OOT BOX DEXTROMETHORPHAN HBR TAB/5MG
LODECON FORTE KAPLET OOT BOX DEXTROMETHORPHAN HBR KAP 15 MG
LODECON KAPLET OOT BOX DEXTROMETHORPHAN KAP/15MG
LUVISMA TABLET PR BOX EFEDRINE HCL TABLET/10 MG
MEZINEX ANTITUSIF 60 ML IFAR MERAH PR FLS PSEUDOEPHEDRINE HCL 30 MG
MEZINEX EXPECTORANT 60 ML IFAR BIRU PR FLS PSEUDOEFEDRIN HCL SYR,30MG
MILLSEN 60ML SIRUP PR FLS PHENYLPROPANOLAMIN HCL SYR/3.5MG
MIXAGRIP FLU&BATUK PE OOT BOX DEXTROMETHORPHAN KAP,10MG
MOLEXFLU KAPLET PR BOX PHENYLPROPANOLMIN HCL KAP12.5MG
MOLEXFLU SYRUP PR FLS PHENYLPROPANOLAMIN HCL SYR/3.125MG
NALGESTAN TAB 25X4 PR BOX PHENYLPROPANOLAMIN HCL TAB 15MG
NEO VEDRIN DROP 10ML PR BTL PSEUDORFEDRINE HCL SYR,7.5MG
NEOZEP F 25X4 PR BOX PHENYLPROPANOLAMIN HCL TAB 15MG
NOVATUSIN SYR 60ML PR FLS PSEUDOEFEDRIN HCL SYR 15MG
OB COMBI ANTITUSIVE 60 ML OOT FLS DEXTROMETHORPHAN HBR SYR 12.5MG
OBH C B/F 60ML ANAK JERUK PR FLS PSEUDOEFEDRINE HCL SYR 7.5 MG
OBH C B/F 60ML ANAK MADU PR BTL PSEUDOEFEDRINE HCL SYR/7.5MG
OBH C B/F 60ML ANAK STRW PR FLS PSEUDOEFEDRINE HCL SYR 7.5MG
OBH C B/F RASA JAHE 60 ML PR BTL EPHEDRINE HCL SYR/2.5MG
OBH COMBI B/F ANAK APEL 60 ML PR BTL PSEUDOEFEDRINE HCL SYR:7.5MG
OBH COMBI B/F MADU DEWASA 100ML PR FLS PSEUDOEFEDRINE HCL SYR:10MG
OBH COMBI B/F MADU DEWASA 60ML PR FLS PSEUDOEFEDRINE HCL SYR:10MG
OBH COMBI B/F MENTHOL 100ML PR FLS PSEUDOEFEDRINE SYR:10MG
OBH COMBI B/F MENTOL 60ML PR FLS PSEUDOEFEDRINE HCL SYR:10MG
OBH TROPICA EXTRA JERUK 60 ML PR BTL PSEUDOEFEDRINE HCL SYR 7.5MG
OBH TROPICA EXTRA MENTHOL 100ML PR FLS EFEDRINE HCL SYR,3MG
OBH TROPICA EXTRA MENTHOL 60 ML PR BTL EPHEDRINE HCL SYR 3MG
OBH TROPICA EXTRA STRWBRY 60ML PR BTL PSEUDOEFEDRIN HCL SYR 7.5MG
OBH TROPICA PLUS JERUK 60ML PR BTL PSEUDOEFEDRIN HCL SYR 7.5MG
OBH TROPICA PLUS MENTHOL 100ML PR BTL EFEDRINE HCL 2.67MG/5ML
OBH TROPICA PLUS MENTHOL 60ML PR BTL EFEDRINE HCL SYR 2.67MG
OBH TROPICA PLUS STRWBRY 60 ML PR BTL PSEUDOEPHEDRINE HCL SYR 7.5MG
OMECOUGH SYR 60ML OOT FLS DEXTROMETHORPHAN HBR SYR 7.5MG
OSKADRYL PE/TAB 4'S CTC OOT BOX DEXTROMETHORPHAN HBR TAB/12MG
PANADOL COLD AND FLU 10BLISTER@10KAPLETPR BOX PSEUDOEFEDRIN HCL KAP,30MG
PANADOL HIJAU FLU DAN BATUK 10X10 OOT BOX DEXTROMETHORPHAN HBR KAP/15MG
PARAFLU CAP 100 PR BOX PHENYLPROPANOLAMIN HCL KAP,12.5MG
PARAFLU SYR PR FLS PHENYLPROPANOLAMINE SYR,3.5MG
PARAMEX FLU&BATUK 25X4 PR BOX PSEUDOEFEDRINE HCL TAB/30MG
PARATENZA SUSPENSI 60 ML IFAR PR FLS PSEUDOFEDRINE HCL SUSP&15MG
PARATUSIN SYR 60 ML * PR FLS PSEUDOEPHEDRINE HCL SYR/7.5MG
PARATUSIN TAB 20X10 * PR BOX PHENYLPROPANOLAMIN HCL TAB/15MG
PASABA COUGH & FLU SYR PR FLS PSEUDOEFEDRINE SYR 15 MG
PIMTRACOL PLUS SYR 60ML CHERRY PR FLS EFEDRIN HCL SYR 2MG
PIMTRACOL PLUS SYR 60ML LEMON PR FLS EFEDRINE HCL SYR 2 MG
PK CITO PR POT PERMANGANAS KALICIUS SERBUK 5GR
QUANTIDEX 10X10 KPL IFAR PR BOX PSEUDOEPHEDRIN HCL KPL/60MG
QUANTIDEX SYR IFARS PR FLS PSEUDOEPHEDRINE HCL SYR/30MG
REMCO BABYCOUGH SYR60ML OOT FLS DEXTROMETHORPHAN HBR SYR 5MG
SILADEX ANTITUSIVE 60 ML (MERAH) OOT BTL DEXTROMETHORPHAN HBR SIR/15MG
SILADEX CC60 ML COUGH N COLD( BIRU) PR FLS PSEUDOEFEDRINE HCL SYR/15MG
SILADEX DMP 60ML OOT FLS DEXTROMETHORPHAN HBR SYR,7.5MG
STOP COLD 15X4 PR BOX PSEUDOEFEDRINE HCL TAB/30MG
TERA F KAPLET 10X10 PR BOX PHENYLPROPANOLAMIN HCL KAP/15MG
TERA F SYRUP 60 ML PR BTL PHENYLPROPANOLAMIN HCL SYR/3.5MG
TERMOREX PLUS 30 ML PR FLS PSEUDOEFEDRINE HCL SYR 7.5MG
TERMOREX PLUS 60 ML PR FLS PSEUDOEFEDRINE HCL SYR7.5MG
TERNIX PLUS SYRUP 60 ML IFAR PR FLS PSEUDOEPHEDRIN HCL SIRUP/15MG
TERNIX SYRUP 60 ML IFAR PR FLS PSEUDOEPHEDRIN HCL SIRUP/15MG
TRANSIFAR 10X10 KPL IFAR PR BOX PHENYLPROPANOLAMIN HCL KAP/12.5
ULTRAFLU KAPLET 25X4 PR BOX PHENYPROPANOLAMIN HCL KAP15MG
VICK F44 ANK ATT & EXP 54ML ~ OOT FLS DEXTROMRTHORPAN HBR SIR/3.5MG
VICK F44 ANK ATT&EXP 27 ML OOT FLS DEXTROMETHORPHAN HBR SIR/3.5MG
VICK F44 DWS ATT 100 ML OOT FLS DEXTROMETHORPHAN HBR SYR,5MG
VICK F44 DWS ATT 27ML ~ OOT BP DEXTROMETHORPHAN HBR SYR 5MG
VICK F44 DWS ATT 54ML ~ OOT FLS DEXTROMETHORPHAN HBR SYR 5MG
WOODS ATT MRH 100ML OOT FLS DEXTROMETHORPHAN SYR,7.5MG
WOODS ATT MRH 60 ML OOT FLS DEXTROMETHORPHAN SYR,7.5MG
ABLET/10 MG
kop APOTEK/KLINIK/RUMAH SAKIT/toko obat/pbf
SURAT PESANAN OBAT MENGANDUNG PREKURSOR FARMASI
No. SP : Harus diisi dengan lengkap
Yang bertanda tangan di bawah ini
Nama : Harus diisi lengkap dengan gelar
Jabatan : Harus diisi
No SIPA utk Apotek/klinik/RS, SIPTTK utk Ass.Apoteker di Toko Obat: harus diisi dengan lengkap
Mengajukan Pesanan obat mengandung Prekursor Farmasi kepada:
Nama PBF : PT. AMAN FARMASINDO ABADI ( harus diisi jangan disingkat)
Alamat : JL.Lawanggada No. 54 -Cirebon ( harus diisi)
Telp : 0231-211567 ( harus diisi)
Jenis obat mengandung Prekursor Farmasi yang dipesan adalah :
Zat Aktif Bentuk
Nama Obat mengandung
No Prekursor dan Satuan JML KET Jumlah
Prekursor Farmasi
Farmasi kekuatan
ditulis
angka dan
1 COPARCETIN SYR 60ML EFEDRINE HCsyr & 4mg/fls ditulis ditulis huruf
angka huruf
latin
obat yang mengandung Prekursor Farmasi tersebut akan digunakan untuk memenuhi kebutuhan
Nama : APOTEK/KLINIK/RUMAH SAKIT/toko obat/pbf (Harus diisi)
Alamat : (Harus diisi lengkap)
No. Ijin : (Harus diisi lengkap)
Cirebon, tgl bln tahun
Pemesan,
(Nama Apoteker)
(No. SIPA hrs diisi lengkap)
STEMPEL
Ket
kop APOTEK/KLINIK/RUMAH SAKIT/toko obat/pbf
SURAT PESANAN OBAT MENGANDUNG OOT FARMASI
No. SP : Harus diisi dengan lengkap
Yang bertanda tangan di bawah ini
Nama : Harus diisi lengkap dengan gelar
Jabatan : Harus diisi
No SIPA utk Apotek/klinik/RS, SIPTTK utk Ass.Apoteker di Toko Obat: harus diisi dengan lengkap
Mengajukan Pesanan obat mengandung OOT Farmasi kepada:
Nama PBF : PT. AMAN FARMASINDO ABADI ( harus diisi jangan disingkat)
Alamat : JL.Lawanggada No. 54 -Cirebon ( harus diisi)
Telp : 0231-211567 ( harus diisi)
Jenis obat mengandung OOT Farmasi yang dipesan adalah :
Zat Aktif Bentuk
Nama Obat mengandung OOT
No OOT dan Satuan Jumlah KET
Farmasi
Farmasi kekuatan
1 LODECON FORTE KAPLET DEXTROMETKAPLET&1 BOX ditulis ditulis
angka huruf
latin
obat yang mengandung OOT Farmasi tersebut akan digunakan untuk memenuhi kebutuhan
Nama : APOTEK/KLINIK/RUMAH SAKIT/toko obat/pbf (Harus diisi)
Alamat : (Harus diisi lengkap)
No. Ijin : (Harus diisi lengkap)
Cirebon, tgl bln tahun
Pemesan,
(Nama Apoteker)
(No. SIPA hrs diisi lengkap)
