REQUEST OF A NON-FORMULARY MEDICATION

Deputyship for Therapeutic Services
General Information: 
• Please read this form completely before filling it out, this form is only to be used when requesting procurement of non-formulary medication for an indication which is approved by the medication regulatory body in one of the following countries/reference regulatory bodies: Kingdom of Saudi Arabia, USA, Canada, UK and EMA. 
• The request of non-formulary medication must be used for regular patient care not for research purposes. 
• Please fill all fields in detailed, kindly send completed PDF form to Pharmaceutical Care Department in your respective hospital. 
• Any incomplete requests will be automatically rejected.
• The procurement processes for the approved request will be done through MOH-ERP system by using pharmacy director account.
For Oncology/Hematology requests:
• Please make sure to attach copy of hospital tumor board recommendations.
 
Please select "print" then "save as PDF" to be communicated with Pharmaceutical Care Department to complete the non-formulary request approvals.

 

1) Date:

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2) Region:

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3) Patient Name:

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4) ID Number:

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5) Nationality:

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6) Gender:

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7) Age (Y):

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8) Weight (Kg):

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9) Hight (m):

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10) Diagnosis:

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11) Request Status:

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12) Generic Name:

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13) Indication:

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14) Present Medical Problem(s): (severity Score if applicable)

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15) Present Medications: (Dose, Frequency, Duration)

 

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16) Past Medical History/ Medication History: (Dose, Frequency, Duration, Response,...)

 

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17) Rational for using non-formulary medication (please include information on previously used treatment modalities which have failed):

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18) Dose:

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19) Frequency:

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20) Duration of treatment:

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21) Requesting Physician:

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22) Dept./Unit:

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23) Specialty:

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24) Rank:

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25) SCFHS No.:

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26) MOH Email:

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27) Contact No.:

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28) "Please select "print" then "save as PDF file" then send to Pharmaceutical Care Department to complete the approval for non formulary application"

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