SOUTH CENTRAL HEALTH DISTRICT PHARMACEUTICAL SUPPLY INTERIM FORM Use for drug requests/transfers, vaccine requests/transfers, expired drug transfers to district pharmacy Requests From: County Requesting Item(s) : To: Date of Request: Approved By: Approved By: Reason for transfer: Reason for request: (Transfers Complete Section 2) – (Requests Complete Section 1, first 2 columns only) – Transfers Section 1 Requests Amt. Amt. Lot # NDC# Manufacturer Exp. Date Needed Issued Section 2 Transfers Amt. Transferred Lot # NDC# Manufacturer Exp. Date Filled By: ___________________________________ Date: _______________ Transported By: ___________________________________ Date: _______________ Received By: ___________________________________ Date: _______________
SOUTH CENTRAL HEALTH DISTRICT PHARMACEUTICAL SUPPLY INTERIM FORM Use for drug requests/transfers, vaccine requests/transfers, expired drug transfers to district pharmacy Requests County Requesting Item(s) : Date of Request: Approved By: Reason for request: (Requests – Complete Section 1, first 2 columns only) Transfers From: To: Approved By: Reason for transfer: (Transfers – Complete Section 2) Section 1 Requests Amt. Needed Amt. Issued Lot # NDC# Manufacturer Exp. Date Section 2 Transfers Amt. Transferred Lot # NDC# Manufacturer Exp. Date Filled By: ___________________________________ Date: _______________ Transported By: ___________________________________ Date: _______________ Received By: ___________________________________ Date: _______________
Order-and-Transfer-form_template_June2016.docx