RCH Drug Usage Committee (DUC)

Committee Approval Form

This form is for completion only by members of the Drug Usage Committee.

If you are seeking approval to use a restricted drug - please contact pharmacy for details.

Note: All fields marked with * are compulsory

Approval:
Patient's name:*	A value is required.
Patient's UR:*	A value is required.
Location: Ward or Outpatient
Drug:*	A value is required.
Duration:
Indication:*	A value is required.
Dose / form:
Requesting Doctor:*	A value is required.
Requesting Unit:*	A value is required.
Requesting consultant:*	A value is required.
Authorising Doctor: *	Please select an item.
Advise Doctor: Enter full email address of recipient
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