Doh-Picu 3

Republic of the Philippines
Allied Care Experts (ACE) Medical Center -Butuan City

South Montilla Blvd., Villa Kananga, Butuan City
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
acemcbutuan@gmail.com
PURCHASE REQUISITION FORM
DEPARTMENT: PR No.:
Pediatric Responsibility Center Code:
Intensive Care Date: 03/13/2023
Unit
Stock/
Estimated
Propert QTY Unit Item Description Total Cost
Unit Cost
y No.
MEDICAL EQUIPMENTS
1 Pc ECG machine (KENTZ) with wheel stand
1 Pc Cardiac monitor with Defibrillator (Portable)
4 Pcs Infusion pump (Terumo)
Portable Oxygen Cylinder with O2 flowmeter (for
1
Pcs E-cart)
2 Pcs Nebulizer
4 Pcs Wall-mount Suction Machine
2 Pcs Portable suction machine
1 Pcs Mechanical Ventilator (Drager)
1 Sets Opthalmoscope Set
1 Sets Otoscope Set
1 Sets Laryngoscope with blades set McBride (Curve)
1 Sets Laryngoscope with blades set McBride (Straight)
1 Pcs Emergency Cart with Cardiac Board
2 Pcs Oxygen Tank with Stand
4 Pcs Wall-mount Oxygen Flowmeter
Oxygen Tank Regulators with flow meters and
2
Pcs Mechanical Ventilator outlet
1 Pcs Procedure Trolley
2 Pcs Portable Pulse Oximeter
1 Pcs Medical Drop Light/Gooseneck Lamp
Manual BP apparatus (Non-mercurial) with
1
Pcs wheel stand with Adult & Pediatric cuff
1 Pcs Stethoscope
2 Pcs Thermometer (Digital)
2 Pcs Bag-valve Mask Unit (Adult)
2 Pcs Bag-valve Mask Unit (Pedia)
2 Pcs Suction Apparatus
`Total: -
Purpose:
EMERGENCY PURCHASE FOR DOH LICENSING
Noted by: Approved by:

Signature: ______________________ ____________________________________
Printed Name: Cherie Mae B.

Ivan Rico G. Madrona DR. GERALDINE MALBAS
Morcillos, RN
Designation: PICU Nurse Warehouse Staff Purchasing Head Department
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
FIXED ASSETS
3 Pcs Mortar and Pestle (Plastic)
2 Pcs Floor Mops
2 Pcs Glass Wiper
2 Pcs Division Curtains
1 Pcs Weighing Scale (for diapers, etc)
2 Pcs Hamper Bag (Wet and Dry)
4 Pcs Soap Dispensers
4 Pcs Paper Towel Dispenser
13 Pcs Garbage Bins (metal)
5 Pcs Alcohol/Sanitizer Dispenser with Holder
4 Pcs Bed Sheet Set
4 Pcs Patient’s Gown
4 Pcs Emergency Light
4 Pc Paper Towel Dispenser
4 Pcs Soap Dispenser

`Total: -
Purpose:

Signature: ______________________ ____________________________________
Printed Name: Cherie Mae B. Morcillos,

RN
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
FIXED ASSETS
1 Pc Medication Refrigerator
3 PcS Flash Light
1 Pc Refrigerator Thermometer
5 Pcs Extension Wires
2 Pcs Wall clock
4 Pcs Office/Swivel Chairs
4 Pcs Monoblock Chairs
1 Pc High Alert Medication/Narcotic Cupboard
`Total: -
Purpose:
Signature: ______________________ ____________________________________

Ivan Rico Madrona DR. GERALDINE MALBAS
RN
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
OFFICE SUPPLIES
4 Plastic Chart Holder
1 Chart Rack
1 White board
1 Cork Board
2 Pen Lights
1 File Rack/Organizer
3 Magazine File Box
2 Calculator
1 Scissors
1 Stapler
1 Tape Dispnser
1 Tape
1 Paste Jar

`Total: -
Purpose:

Signature: ______________________ ____________________________________
Printed Name: Cherie Mae B. Morcillos Ivan Rico G. Madrona DR. GERALDINE MALBAS
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
MEDICAL SUPPLIES
2 Pcs Aseptic Bulb Syringe
1 Set Capillary Blood Glucose Kit
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
10 Pcs ETT Size 3.5

10 Pcs ETT Size 4.0
10 Pcs ETT Size 4.5
10 Pcs ETT Size 5.0
10 Pcs ETT Size 5.5
10 Pcs ETT Size 6.0
10 Pcs ETT Size 6.5
10 Pcs ETT Size 7.0
10 Pcs ETT Size 7.5
10 Pcs Suction Catheter Fr 8
20 Pcs Sterile Gloves Size 8.5
2 Box Glomed Non-Sterile Gloves (100pcs/box) Large
Glomed Non-Sterile Gloves (100pcs/box)
2
Box Medium
2 Box Glomed Non-Sterile Gloves (100pcs/box) Small
`Total: -
Purpose:

Signature: ______________________ ____________________________________

RN
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
MEDICAL SUPPLIES
4 Pcs Nasal Cannula Pediatric
4 Pcs Nasal Cannula Adult
3 Pcs Face Shield/Goggles
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
1 box Sterile Gauze

10 Pcs Sterile Gauze Individually Packed (4x4)
5 Pc Syringe 50cc
5 Pc Syringe 30cc
5 Pc Syringe 10cc
5 Pc Syringe 5cc
5 Pc Syringe 3cc
5 Pc Syringe 1cc/ Tuberculin
5 Pc Insulin syringe (100units/1ml)
10 Pcs Foley Catheter Fr 6
10 Pcs Foley Catheter Fr 8
10 Pcs Foley Catheter 10
10 Pcs Straight Catheter Fr 6
10 Pcs Straight Catheter 12
10 Pcs Straight Catheter 14
10 Pcs Urine Collection Bag
10 Pcs Water Aprons
10 Pcs Cotton
`Total: -
Purpose:

Signature: ______________________ ____________________________________

RN
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
EMERGENCY CART MEDICATION

20 Β-adrenergic agonists (i.e. Salbutamol 2mg/ml)
10 5 Caloric agent (D50W 50mg/vial)
20 Activated charcoal sachet
10 Amiodarone 150mg/ampule
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
5 Anti-rabies vaccine (active)

5 Anti-rabies vaccine (passive)
Anti-tetanus serum (either equine-based
40
antiserum or human antiserum)
Anti-venims* (for centers with high incidence of
poisonous animal bites)
20 Aspirin USP grade (325 mg/tablet)
15 Atropine 1mg/ml ampule
Benzodiazipine (Diazepam 10mg/2ml ampule
10 and/or Midazolam
Calcium (usually calcium gluconate

10
10mg/ampule)
10 D5 0.3 NaCl 500ml/bottle
10 D5 LR 1L/bottle
10 D5 NSS 1L/bottle
10 Digoxin 0.5mg/ampule
10 Diphenhydramine 50mg/ampule
10 Dobutamine 250mg/20ml vial
10 Dopamine 20mg/vial
30 Epinephrine 1mg/ml ampule
20 Furosemide 20mg/2ml ampule
10 Haloperidol 50mg/ampule
10 Hydrocortisone 250mg/vial
5 Hyoscine N-butyl-bromide 20mg/vial
`Total: -
Purpose:

Signature: ______________________ ____________________________________
Printed Name: Cherie Mae B. Glazzy Anne Farah M. Labadan,

DR. GERALDINE MALBAS
Morcillos,RN RPh
Designation: PICU Nurse Chief Pharmacist Purchasing Head Department
DEPARTMENT: PR No.:
Unit
Stock/
Estimated
Unit Cost
y No.
EMERGENCY CART MEDICATION

20 Lidocaine 5% solution vial 1g/50ml
10 Magnesium sulfate 1g/ampule
10 Mannitol 20% solution 500ml/vial
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
10 Mefenamic Acid 500mg/tablet

10 Methylprednisolone 4mg/tablet
5 Metoclopramide 10mg/ampule
10 Morphine sulfate 10mg/ampule
Nitroglycerin spray or Isosorbide dinitrate 5mg
10
tablet/ampule
2 Noradrenaline 2mg/ampule
Oral Rehydration Solution salt preparation
10
sachet
15 Paracetamol 300mg/ampule (IV preparation)
15 Phenobarbital 30mg/ml IV or 30mg tablet
15 Phenytoin 300mg/capsule or IV preparation
10 Plain LRS 1L/bottle
10 Plain NSS 1L/bottle
15 Potassium Chloride 40mEq/vial
10 Pyridoxine 1g/ampule
10 Sodium bicarbonate 50mEq/ampule
5 Succinylcholine 200mg/vial
20 Tetanus Toxoid 0.5ml/vial
Thiamine (usually in parenteral Vitamin B
10
complex preparation)
10 Tramadol 50mg/capsule
10 Verapamil 5mg/2ml ampule
`Total: -
Purpose:

Signature: ______________________ ____________________________________
Printed Name: Cherie Mae B. Morcillos, Glazzy Anne Farah M. Labadan,

DR. GERALDINE MALBAS
RN RPh
Designation: PICU Nurse Chief Pharmacist Purchasing Head Department
DEPARTMENT: PR No.:
Intensive Care Responsibility Center Code: Date: 03/13/2023
Unit PEDIATRIC INTENSIVE CARE UNIT
Stock/
Estimated
Unit Cost
y No.
MEDICAL INSTRUMENT
2 Forster Sponge Holding Forceps
14 Backhaus Towel Clamp
10 Bard-Parker Scalpel Holder No. 3
2 Iris Scissors
Tel No. (085) 342-4874/0933-051-6947/0915-735-5076
2 Metzenbaum Dissecting Scissors

5 Operating Scissors
5 Adson Dressing Forceps
2 Adson Dissecting Fouspens
2 Weirtlawer Self Retaining Retractor
2 Wound Retractor
10 Halsted-Mosquito Artery Forceps
2 Butterfly Probe/Grooved Director
2 Mayo-Hegar Needle Holder
3 Mayo Tray
2 Mayo Stand
3 Crile-Wood Needle Holder
2 Kidney Dish
3 Thumb Forceps with Tooth
3 Thumb Forceps without Tooth
3 Forceps Jar
3 Marilla Fercep (adult/pedia)
6 Cottonballs Jar
`Total: -
Purpose:

Signature: ______________________ ____________________________________

RN

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Doh-Picu 3

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Republic of the Philippines

Allied Care Experts (ACE) Medical Center -Butuan City

PURCHASE REQUISITION FORM

Noted by: Approved by:

Printed Name: Cherie Mae B.

PURCHASE REQUISITION FORM

Noted by: Approved by:

Printed Name: Cherie Mae B. Morcillos,

PURCHASE REQUISITION FORM

Printed Name: Cherie Mae B. Morcillos,

PURCHASE REQUISITION FORM

Noted by: Approved by:

PURCHASE REQUISITION FORM

10 Pcs ETT Size 3.5

Noted by: Approved by:

Printed Name: Cherie Mae B. Morcillos,

PURCHASE REQUISITION FORM

1 box Sterile Gauze

Noted by: Approved by:

Printed Name: Cherie Mae B. Morcillos,

PURCHASE REQUISITION FORM

EMERGENCY CART MEDICATION

5 Anti-rabies vaccine (active)

Calcium (usually calcium gluconate

Noted by: Approved by:

Printed Name: Cherie Mae B. Glazzy Anne Farah M. Labadan,

PURCHASE REQUISITION FORM

EMERGENCY CART MEDICATION

10 Mefenamic Acid 500mg/tablet

Noted by: Approved by:

Printed Name: Cherie Mae B. Morcillos, Glazzy Anne Farah M. Labadan,

PURCHASE REQUISITION FORM

2 Metzenbaum Dissecting Scissors

Noted by: Approved by:

Printed Name: Cherie Mae B. Morcillos,

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