APPLICATION DOCUMENTS FOR HOSPITAL PHARMACY

GENERAL INFORMATION

Name of Pharmacy
Business Address


Name of Owner
Contact Numbers Tel. No. Fax
Chief of Hospital
Medical Director
Chairman of the Board
(if Corporation)
Name of Chief Pharmacist

Reg# Date Issued Validity
Bed Capacity

CLASSIFICATION
OWNERSHIP FUNCTION SERVICE CAPABILITY
( ) Government ( ) General ( ) Level 1
( ) Outsourced ( ) Special ( ) Level 2
( ) Private ( ) Level 3
( ) Outsourced ( ) Level 4

STATUS OF APPLICATION
( ) Initial / Opening ( ) Renewal
LTO No. ______________________
Date Issued: __________________
Validity: _____________________

CHECKLIST:
1. For INITIAL or RENEWAL, please tick the appropriate boxes under Column B or C and provide necessary documents.
2. Items shaded are not required. HOWEVER, if there are changes in information upon RENEWAL, please tick appropriate
boxes under column C and provide necessary documents/requirements.
3. During inspection, refer to Annex 1 and provide necessary documents.
A
DOCUMENTS
B
INITIAL APPLICATION
C
RENEWAL APPLICATION
1 List of Personnel
- All pharmacist under employ
- Pharmacy Aide
- Salesclerk
2
Proof of Qualification of Pharmacist/s
(Note: Present all original documents)
- Board Certificate
- Valid PRC-ID

- Certificate of Training in Licensing of
Drug Establishments & Outlets
3 List of Products
4 Memorandum of Agreement, if not
owned by the hospital (refer to Annex 1
for additional requirements)