FKP Online
FORMULIR KELUHAN PRODUK
(
Complaint Product Form
)
Informasi Pasien (
Patient Information
)
Nama/Inisial Pasien (
Patient Name/Initials
) :
Usia (
Age
) :
Jenis Kelamin (
Gender
) :
Pilih (
Choice
)
Laki-laki (
Male
)
Perempuan (
Female
)
Informasi Produk (
Product Information
)
Nama Produk(
Product Name
) :
Pilih (
Choice
)
ADIXON
AKNIL KAPLET
ANHISSEN SYRUP
ANHISSEN TABLET 10 MG
APISATE TABLET
APISATE TABLET E
ATIVAN 0.5 MG
ATIVAN 1.0 MG
ATIVAN 2.0 MG
BEFIT KAPLET
BEZALIP Retard Tablet
CALMLET 0.5 MG
CALMLET 1.0 MG
CANCID 150 MG
CLONAZEPAM 2 MG
CLOZAPINE 100 MG
CLOZAPINE 100 MG E
CLOZAPINE 25 MG
CLOZAPINE 25 MG E
CSB SERBUK INJ 1 GR & PELARUT 5 ML
CYCLO PROTHYRA
CYCOZAM 100 MG
CYCOZAM 100 MG BPJS
CYCOZAM 100 MG BPJS
CYCOZAM 25 MG
CYCOZAM 25 MG BPJS
CYCOZAM 25 MG BPJS
DEPO PROTHYRA
ESTHERO 0.625 MG
ESTHERO 0.625 MG BPJS
EUFORISS 2 MG TAB
FEBRYN SYRUP
GUNACETA 500 MG
GUNACETA 650 MG
GUNAPECT
L-CARNIQ10 30 S
LAVIGEN B BOTOL 30 S
LAVIGEN CREAM 30 GR
LAVIGEN S BOTOL 60 S
LIPOFIBRAT 200 MG
LIPOFIBRAT 300 MG
LORAZEPAM 2 MG
MOXTID 500 MG
OBSTANON
ORLISTAT 120 MG CAPS BOX/30
PAEDILAC 4.7 x 107 cfu/g NEW
PONTHYAMER B6
PRELAMIN - F
PROLANZ 30 MG
PROTHYRA 10 MG
PROTHYRA 10 MG (E)
PROTHYRA 5 MG
SENTYL 500 MG
SIMECO TABLET
TRINORDIOL 28 LIMAS
VICO BEAUTY CAPS BOX/60
VISTAT 120 MG KAPSUL
VITASI
Bentuk Sediaan (
Product Type
) :
Pilih (
Choice
)
Tablet (
Tablet
)
Sirup (
Syrup
)
Kapsul (
Capsule
)
Nomor Bets (
Batch Number
) :
Ketersediaan Sampel (
Sample Availability
) :
Pilih (
Choice
)
Ada (
There is
)
Tidak Ada (
There isn't any
)
Lengkapi Foto (
Picture
) :
Deskripsi Keluhan (
Complaint Information
) :
Informasi Pelapor (
Reporter Information
)
Nama(
Name
) :
Telepon (
Phone
) :
Alamat Email (
E-Mail
) :
Tanggal Pelaporan (
Date Report
) :
Alamat (
Address
) :
Isilah nilai hasil Perhitungan di bawah ini (
Fill in the calculation result values below
):