Master Formulation Record

Pharmacy compounding of non-sterile preparations

Name of compounded product: Protocol number and version:

Concentration: Effective date:

(dd/mm/yy)

Pharmaceutical form: Developed by:

Route of administration: Verified by:

Formula

Ingredients: Quantities: Physical description: Other information (i.e.

DIN, lot number, man-
ufacturer, expiry date,
expected yield)

Additional information about the ingredients:

Notes on calculations and measurements:

Required equipment, instruments, and materials:

Compounding method:

Quality controls:

Packaging:
Stability and storage:

Labelling: Sample label:

Patient label:

Training:

References consulted:

Preparation date sheet history #:

Revised: Revised by:
(dd/mm/yy)

Change made:

Version number changed: Yes No

Revised: Revised by:

(dd/mm/yy)

Change made:

Version number changed: Yes No