Държавен вестник, бр. 95, 2011 г., стр. 71

БРОЙ  95	
Д Ъ Р Ж А В Е Н  В Е С Т Н И К 	
СТР.  71  
3. Кратка анамнеза и статус:................................................................................................................................
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4. Диагноза:...............................................................................................................................................................
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5. Провеждано досега лечение:............................................................................................................................
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6. Изписването на лекарствения продукт се налага поради:
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7. Предписва се:
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(търговско наименование на лекарствения продукт, вид на лекарствената форма и количество на активното 
вещество в дозова единица, количество в една опаковка)
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(международно непатентно наименование на активното вещество)
8. Необходимо количество:....................................................................................................................................
(брой опаковки, с цифри и думи)
9. Лице, коeто ще осъществи доставката на лекарствения продукт:
……………………………………………………………………………………………...........................................................................…………….
(име, адрес, телефон)
Комисия:
	
1.	 ..................................................................................................................................................................
(подпис)
	
2.	 .....................................................................................................................................................................
(подпис)
	
3.	 ......................................................................................................................................................................
(подпис)
Утвърждавам: .......................................................................................................................................................
(трите имена на ръководителя на лечебното заведение)
Подпис:
Печат:
Отпуснато количество: ..............................................................................................................................................
Отпуснал: .................................................................................................................................................................
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(име, фамилия, длъжност)
Подпис:
Получил:................................................................................................................................................................
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(име, фамилия, данни л.к. №)
Подпис:                                                     Дата: