ANNEX G-6

PURCHASE REQUEST
Provincial Government of Sorsogon
LGU
Department: BMH PR No.:__________________ Date:_______________
Section : SAI No.__________________ Date:_______________
ALOBS No:_______________ Date:_______________
Unit of Stock Estimated
Quantity Item Description Estimated Cost
Issue No. Unit Cost
DRUGS & MEDICINES

-
400 sachet Acetylcysteine 600mg sachet 18.90 7,560.00
1000 cap Amoxicillin 500mg capsule 1.28 1,280.00
200 cap Amoxicillin 250mg capsule 1.06 212.00
50 bot Amoxicillin 250mg/ml 60ml susp 250mg/5ml 22.00 1,100.00
200 vial Ampicillin+Sulbactam 500mg+250mg vial 27.00 5,400.00
100 vial Ampicillin 1gram vial 15.00 1,500.00
70 vial Ampicillin 250mg vial 9.75 682.50
100 vial Ampicillin 500mg vial 8.21 821.00
80 bot Ascorbic Acid 100mg/5ml drops 17.50 1,400.00
2000 tablet Ascorbic acid (vitamin C)500mg tablet 0.80 1,600.00
1000 tablet Aspirin 80mg tablet 0.70 700.00
100 bot Ascorbic Acid 100mg/5ml 60ml syrup 20.14 2,014.00
100 tablet Azithromycin 500mg tablet 13.00 1,300.00
200 tablet Atorvastatin 40mg tab 9.24 1,848.00
600 tablet Bisacodyl 5mg tablet 1.78 1,068.00
300 tablet Betahistine 16mg tab 11.00 3,300.00
200 nebule Budesonide 250mcg/ml 2ml resp. nebule 38.00 7,600.00
300 tablet Butamirate Citrate 50mg MR tablet 12.50 3,750.00
100 bot Cefalexin 100mg/ml 10ml drops bot 18.00 1,800.00
150 bot Cefalexin 250mg/ml 60ml susp 250mg/5ml 28.00 4,200.00
2000 cap Cefalexin 500mg cap 2.85 5,700.00
200 vial Ceftriaxone 1 1g + 10ml diluent 18.56 3,712.00
Cefuroxime
500 tablet 500mg tablet 500mg tablet 12.00 6,000.00
Cefuroxime
200 vial Celecoxib 750mg vial 17.50 3,500.00
500mg tablet
600 cap 200mg200mg 200mg capsule 3.50 2,100.00
400 capsule
tablet Ciprofloxacin 500mg tablet 2.75 1,100.00
Cetirizine 10mg
700 tablet tablet tablet 0.40 280.00
60 bot Cetirizine 10mg/ml,60ml bottle 37.94 2,276.40
500 cap Clindamycin 300mg, Capsule 5.35 2,675.00
80 ampule Clindamycin 150mg/ml ampule (4ml) 80.00 6,400.00
1000 tablet Clonidine 75mcg tablet 5.50 5,500.00
100 ampule Clonidine 150mcg/ml ampule 115.00 11,500.00
Cotrimoxazole(Su
1000 capsule Cloxacillin (as sodium)
lfamethoxazole + 500mg capsule 2.78 2,780.00
600 tablet Trimetophrim) 1.90 1,140.00
400 tablet 800mg
tablet
+ 160mg
Co- Amoxiclav 625mg tablet 9.00 3,600.00
50 bot Dicycloverine 10 mg/5ml syrup 60ml (10mg/5mL) 15.00 750.00
Diphenhydramine (as Hydrochloride) 50mg/ml,1ml
100 ampule ampule 20.00 2,000.00
30 bot Diphenhydramine 12.5mg/5ml 60ml syrup 18.66 559.80
SUB-TOTAL 110,708.70
 Purpose: For the subsistence of Bulan Medicare Hospital
Funds Available: Approved by:
Signature
Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA MARIA LORIELYN D. TE EDWIN "BOBOY'' B.HAMOR

Acting Provincial
Designation Acting Provincial Health Officer Treasurer-OIC Governor

Provincial Government of Sorsogon

PURCHASE REQUEST
LGU

Department: BMH PR No.:__________________ Date:_______________

Section : SAI No.__________________ Date:_______________

ALOBS No:_______________ Date:_______________
Unit of Stock Estimated
Quantity Item Description Estimated Cost
Issue No. Unit Cost
DRUGS AND MEDICINES

1,000 tablet Ferrous Salt equiv to 60mg elem iron tab 1.00 1,000.00
Ferrous Salt + FA equiv to 60mg elem iron + 40mcg
1,000 cap Folic Acid cap 0.89 890.00
200 ampule Hyoscine (as N-butylbromide)20mg /1ml ampule 17.23 3,446.00

1,000 tablet Hyoscine (as N-butylbromide)10mg tablet 3.84 3,840.00

150 ampule Hydralazine 20mg/ 1ml ampule 27.88 4,182.00

150 vial Hydrocortisone 100mg vial -100mg powder 18.78 2,817.00

100 vial hydrocortisone 250mg vial-250mg powder 54.32 5,432.00
500 nebule Ipra+ Salbutamol Neb 500mcg +2.5mg(2ml) 10.00 5,000.00
300 tablet Isosorbide Dinitrate 5mg sublingual tablet 8.00 2,400.00
50 bot Lagundi300mg/ml,120ml syrup bottle 70.72 3,536.00
300 tablet Lagundi 300mg tablet 1.75 525.00

400 tablet Lagundi 600mg tablet 2.70 1,080.00

50 vial Lidocaine 2% 50ml vial 60.00 3,000.00

2000 tablet Losartan 100mg tablet 2.50 5,000.00
4000 tablet Losartan 50mg tablet 0.88 3,520.00
150 ampule Ketorolac 30mg/ml,1ml ampule 25.00 3,750.00
 1000 capsule Mefenamic Acid 500mg capsule 1.40 1,400.00

1,000 tablet Metformin 500mg tablet(as hydrochloride) 0.59 590.00

300 tablet Metronidazole 500mg tablet 1.50 450.00

300 vial Metronidazole 5mg/ml vial 100ml 14.17 4,251.00
80 bot Multivitamins per 1ml,15ml drops 22.85 1,828.00
150 bot Multivitamins per 5ml,60ml syrup 19.60 2,940.00
25 ampule Nicardipine 1mg/ml ,10ml ampule 205.00 5,125.00
400 capsule Omeprazole 40mg cap 4.23 1,692.00
300 vial Omeprazole 40mg powder vial + 10ml solvent amp 27.00 8,100.00
3000 sachet Oral Rehydration Salts 20.5g sachet(ORS 75-replacement 3.64 10,920.00
100 bot Paracetamol 100mg/ml drops 15ml 16.00 1,600.00
100 bot Paracetamol 250mg/5ml syrup 60ml 17.80 1,780.00
200 ampule Ranitidine 25mg/ml 2ml ampule 7.00 1,400.00
300 nebule Salbutamo 1mg/ml 2.5ml nebule 9.00 2,700.00
100 ampule Serum, ATS 1500 iu / 0.7ml amp (equine) 130.00 13,000.00
300 ampule Tramadol 50mg/ml,2ml ampule 6.38 1,914.00
1000 tablet Trimetazidine 35mg tablet 3.92 3,920.00

100 ampule Tranexamic acid 100mg/ml,2ml ampule 24.00 2,400.00

200 ampule Vaccine,Tetanus toxoid 0.5ml 69.00 13,800.00

3000 tablet Vitamin B!,B6,B12 tablet 100mcg+5mg+50mcg 1.50 4,500.00

300 ampule Vit B1,B6,B12 amp 100mg+100mg+1mg(3ml) 32.00 9,600.00

Zinc 55mg(Equiv.to 20mg Elemental Zinc),60ml syrup
32 bot bottle 38.00 1,216.00
144,544.00

Purpose: For the subsistence of Bulan Medicare Hospital

Funds Available: Approved by:
Signature

Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA MARIA LORIELYN D. TE EDWIN "BOBOY" B. HAMOR

Acting Provincial
Designation Acting Provincial Health Officer Treasurer-OIC Governor

ANNEX G-6

PURCHASE REQUEST
Provincial Government of Sorsogon
LGU
PR No.:__________________ Date:_______________
Section :BMH SAI No.__________________ Date:_______________
ALOBS No:_______________ Date:_______________
Unit of Stock Estimated
Quantity Item Description Estimated Cost
No.
 Stock
Quantity Item Description Estimated Cost
Issue No. Unit Cost

IV FLUIDS

300 bot IV Fluids,0.9% Sodium Chloride1Liter 78.00 23,400.00

192 bot IV Fluids,0.9% Sodium Chloride 500cc 75.00 14,400.00
72 bot IV Fluids 5% Dextrose 0.3 Sodium Chloride 500cc 75.00 5,400.00
120 bot IV Fluids 5% Dextrose 0.3 Sodium Chloride 1 liter 55.00 6,600.00

300 bot IV Fluids Lactated Ringer's Solution 1Liter 82.00 24,600.00

192 bot IV Fluids Lactated Ringer's Solution 500cc 70.00 13,440.00

192 bot IV Fluids, 5% Dextrose Lactated Ringer"s Solution 500cc 58.00 11,136.00
72 bot Mannitol 500cc 140.00 10,080.00
SUB-TOTAL 109,056.00

CERTIFICATION:

This is to certify tha the Drugs being requisitioned

herein fall within conform with PNDF volume 1,7 and
8 edition

JEROME G. ESCAÑO,MD
MO III/ Chief of Hospital

TOTAL 364,308.70

Purpose: For the subsistence of Bulan Medicare Hospital

Funds Available: Approved by:
Signature

Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA MARIA LORIELYN D. TE EDWIN"BOBOY" B.HAMOR

Acting Provincial
Designation Acting Provincial Health Officer Treasurer-OIC Governor
 ANNEX G-6

PURCHASE REQUEST
Provincial Government of Sorsogon
LGU
Department: BMH PR No.:__________________ Date:_______________
Section : SAI No.__________________ Date:_______________
ALOBS No:_______________ Date:_______________
Unit of Stock Estimated
Quantity Item Description Estimated Cost
Issue No. Unit Cost

MEDICAL SUPPLIES

10 bottle Alcohol 70%, Ethyl 500ml 107.70 2154.00

6 gallon Alcohol 70%, Ethyl 440.00 2640.00
3 roll Cotton 400mg 197.40 592.20
5 box Disposable Syringe w/Needle 10cc,100's 375.00 1875.00
10 box Disposable Syringe w/Needle 3cc,100's 260.00 2600.00
10 box Disposable Syringe w/Needle 1cc,100's 260.00 2600.00
10 roll Elastic Bandage 2" 230.00 2300.00
10 roll Elastic Bandage 4" 230.00 2300.00
2 roll Gauze Roll 28*24*36*100 1341.00 2682.00
10 box Hypo Allergenic Plaster 1"*12 535.80 5358.00
15 box Hypo Allergenic Plaster 1/2"*24 564.00 8460.00
5 box Insulin Syringe 0.5cc,100's 785.00 3925.00
300 pc IV Cannulas G22 18.33 5499.00
300 pc IV Cannulas G24 18.33 5499.00
400 pc IV Cannulas G26 18.33 7332.00
40 pc Leukoplast 1.25cm x 1m 60.00 2400.00
200 pc Macroset 15.51 3102.00
200 pc Microset 16.92 3384.00
7 pc Plaster of Paris 4" 150.00 1050.00
24 pc Silk 1/0 ,cutting 105.00 2520.00
20 pc Soluset.Microdrops 126.90 2538.00
5 box Surgical Gloves,6.5", 50's 660.00 3300.00
5 box Surgical Gloves,7", 50's 660.00 3300.00
2 box Topical Anesthesia 400.00 800.00
SUB-TOTAL 78,210.20

Purpose: For the subsistence of Bulan Medicare Hospital

Funds Available: Approved by:
Signature
Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA MARIA LORIELYN D. TE EDWIN "BOBOY" B.HAMOR

Acting Provincial
Designation Acting Provincial Health Officer Treasurer-OIC Governor
 ANNEX G-6

PURCHASE REQUEST
Provincial Government of Sorsogon
LGU
Department: BMH PR No.:__________________ Date:_______________
Section : SAI No.__________________ Date:_______________
ALOBS No:_______________ Date:_______________
Unit of Stock Estimated
Quantity Item Description Estimated Cost
No.
Issue Unit Cost

2 gallon Cidex sterilizing solution 1,500.00 3,000.00

10 box Clean Gloves, unsterile ,large 50's 550.00 5,500.00
10 box Clean Gloves, unsterile ,medium 50's 550.00 5,500.00
SUB-TOTAL 14,000.00

TOTAL 92,210.20

Purpose: For the subsistence of Bulan Medicare Hospital

Funds Available: Approved by:
Signature
Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA MARIA LORIELYN D. TE EDWIN "BOBOY" B.HAMOR

Acting Provincial
Designation Acting Provincial Health Officer Treasurer-OIC Governor
PURCHASE REQUEST
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 ANNEX G-6

PURCHASE REQUEST
Provincial Government of Sorsogon
LGU

Department: PGGMH PR No.:__________________ Date:_______________

Section : SAI No.__________________ Date:_______________
ALOBS No:_______________ Date:_______________
Unit of Estimated
Quantity Item Description Stock No. Estimated Cost
Issue Unit Cost

Purpose: For the use of Pantaleon G. Gotladera Memorial Hospital

Requested by: Funds Available: Approved by:
Signature
Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA BELINDA J. GACOSTA FRANCIS JOSEPH G. ESCUDERO
Printed Name RENATO B. BOLO JR.,MD,MHA,CHA,FPCHA BELINDA J. GACOSTA FRANCIS JOSEPH G. ESCUDERO

Designation ACTING PROVINCIAL HEALTH OFFICER Provincial Treasurer-OIC Governor