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
CLOMIFIL 50 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
CYNTOCIN - AMP BOX/10
DEPO PROTHYRA
ESTHERO 0.625 MG
ESTHERO 0.625 MG BPJS
EUFORISS 2 MG TAB
FEBRYN SYRUP
GUNABION KAPLET 100 S
GUNACETA 500 MG
GUNACETA 650 MG
GUNACOLD
GUNAPECT
LAVIGEN CAPS BOX/60
LIPOFIBRAT 200 MG
LIPOFIBRAT 300 MG
LONENE 200 MG
LONENE 300 MG
LORAZEPAM 2 MG
MOXTID 500 MG
NOSTHYRA 5 MG
OBSTANON
PAEDILAC 4.7 x 107 cfu/g NEW
PONTHYAMER B6
PRELAMIN - F
PROBIOLAC
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
):