Appendix 60

PURCHASE REQUEST

Entity Name: CONRADO F. ESTRELLA REGIONAL MEDICAL AND TRAUMA CENTER Fund Cluster: _____________
Office/Unit : Purchase Request No.:
Date:
Responsibility Center Code:
Stock/ Property
Unit Item Description Quantity Unit Cost Total Cost
No.
Amlodipine (as besilate/camsylate) 10
capsule 2500 3.00 7,500.00
mg tablet
Amoxicillin (as trihydrate) 500 mg
box 5000 7,000.00 35,000,000.00
capsule
chromic round and cutting 3.0
box 5 300.00 1,500.00
12PCS/BOX
Ciprofloxacin (Ciprosan ®) 500 mg
box 5000 143.00 715,000.00
tablet
tablet Clarithromycin 500 mg tablet 1000 19.36 19,360.00
Co-amoxiclav (amoxicillin+potassium
tablet 1000 50.00 50,000.00
clavulanate) tablet
roll Gauze Roll 24x28, 2kg/roll 10 1,300.00 13,000.00
ampule Lidocaine 4% 10mg/ml, 50 ml vial 300 40.60 12,180.00
Losartan (as hydrochloride) 150 mg
tablet 2500 14.30 35,750.00
tablet
Metformin (as hydrochloride) 500 mg
box 2500 60.00 150,000.00
film coated tablet
tablet Metoprolol (as tartrate) 50 mg tablet 2500 1.04 2,600.00
Oral Reydration Salt (ORS 75-
box 1250 10,150.00 12,687,500.00
replacement) 20.5g sachet
tablet Paracetamol 5000 0.49 2,450.00
Paracetamol 100mg/ml drops (alcohol-
carton 300 2,376.00 712,800.00
free), 15ml
Salbutamol 2 mg/10 mL, 120 mL
bottle 200 25.35 5,070.00
Syrup Bottle
box Simvastatin 40 mg capsule 2500 154.00 385,000.00
box syringe,10cc 100pcs/box 10 500.00 5,000.00
--Nothing Follows--

Source of Fund:
TOTAL 49,804,710.00
Purpose: For the use of E-Konsulta Program of Conrado F. Estrella Regional Medical and Trauma Center

Requested by: Approved by:

_____________________________________________
Signature: _______________________________
___________________________________________
Printed Name: EMERSON B. PATAWARAN, MD, MHA, FPNA PAULA PAZ M. SYDIONGCO,MD,MPH,MBA,CESO IV
Designation: Medical Center Chief I Director IV

Accountable Officer:

MARK DAVE RODRIGO, RN, MAN

NURSE V

Clearance (for the ff. if applicable) Signature/Initial Date

Procurement
Warehouse (Office Supplies)

Pharmacy and Therapeutics Committee

(Drugs & Medicines)

HEPU (IEC & other promotional materials)

DIVISION CHIEF (Venue Rental and
Catering Services)
HRDU (Board & Lodging)

HFEP (Medical/Dental/Hospital/Laboratory
Equipment & Infra)

ICT (IT Supplies and Equipment)

GSS (Van Rental)
Budget (Availability of Funds)
TWG (Others, please include the name of
TWG Member)