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HOLY NAME UNIVERSITY MEDICAL CENTER, INC.

0476 HNU Campus, J. A. Clarin ST., Dampas District, Tagbilaran City, Bohol 6300
Tel. Nos.: (038) 501-9946 to 47 412-0915 to 16 , (telefax) 501-9948 Page 1 of 2
Website: hnu-mcfi.org., email add: hnumcfi_svd@yahoo.com.ph

Summary Report of Transactions on Dangerous Drug and /or Drug Preparations containing Controlled Chemical
(To be submitted by licensed retailers and users for laboratory use/ or programs for medical, scientific research or instructional/ training purpose)
For the period of June 1 to December 31, 2018

Name of Company/ Entity___ Holy Name University Medical Center, Inc. S-License Number___ S3-030540001-R076-H
Address _________________ 0476 HNU Campus, J.A. Clarin St., Dampas Dist., Tagbilaran City Validity ___________ 3/25/2019
Contact Details (tel/fax/email)_ 501-9946
Name of Drug Beginning Total Quantity Received Name of Supplier Total Quantity Received End Remarks
Indicate Dosage Strength and Balance Purchased per Others (ex. Return Sold/ Others (ex. Surrender/ return Balance
Inform Supplier stocks from clients Used stock to suppliers/loss, etc
DEMEROL 100MG/2ML 0 NONE ZUELLIG PHARMA INC.
17 39 NONE 28
AMP 50 NONE I. CON TRADE
200 NONE ZUELLIG PHARMA INC.
DORMICUM 5MG AMP 170 100 NONE I. CON TRADE 317 NONE 153
FENTANYL CITRATE 0 NONE ZUELLIG PHARMA INC.
324 171 NONE 153
100MCG AMP 0 NONE I. CON TRADE
0 NONE ZUELLIG PHARMA INC.
KETAMINE VIAL 10ML 9 9 NONE 0
0 NONE I. CON TRADE
100 NONE ZUELLIG PHARMA INC.
DORMICUM 15MG/3ML AMP 38 55 NONE 113
30 NONE I. CON TRADE
Note: Fill-out all columns. Indicate n/a if not applicable. Indicate no then follows after the last drug entry. Summary Report (January to June or July to December) and Register are to be submitted and presented
respectively not later than 15 days after the covered period. Late submission shall be accompanied by an affidavit stating circumstances of the delay. If report covers more than 1 page, sign all pages.

CERTIFIED TRUE AND CORRECT. FURTHER CERTIFY THAT AFOREMENTIONED END BALANCE TALLIES WITH THE ACTUAL INVENTORY AS OF __
DECEMBER 31, 2018

MARIA ZINDA A. MOLINA-MAJOMETANO REV. FR. MICHAEL P. TANGENTE S.V.D.


Printed Name and Signature of Authorized Pharmacist Printed Name, Designation and Signature of Head
1/3/2018
Date Prepared
HOLY NAME UNIVERSITY MEDICAL CENTER, INC.
0476 HNU Campus, J. A. Clarin ST., Dampas District, Tagbilaran City, Bohol 6300
Tel. Nos.: (038) 501-9946 to 47 412-0915 to 16 , (telefax) 501-9948 Page 2 of 2
Website: hnu-mcfi.org., email add: hnumcfi_svd@yahoo.com.ph

Summary Report of Transactions on Dangerous Drug and /or Drug Preparations containing Controlled Chemical
(To be submitted by licensed retailers and users for laboratory use/ or programs for medical, scientific research or instructional/ training purpose)
For the period of June 1 to December 31, 2018

Name of Company/ Entity___ Holy Name University Medical Center, Inc. S-License Number___ S3-030540001-R076-H
Address _________________ 0476 HNU Campus, J.A. Clarin St., Dampas Dist., Tagbilaran City Validity ___________ 3/25/2019
Contact Details (tel/fax/email)_ 501-9946
Name of Drug Beginning Total Quantity Received Name of Supplier Total Quantity Received End Remarks
Indicate Dosage Strength and Balance Purchased per Others (ex. Return Sold/Used Others (ex. Surrender/ Balance
Inform Supplier stocks from clients return stock to
suppliers/loss, etc
0 NONE ZUELLIG PHARMA INC.
NUBAIN 10MG AMP 200 NONE
0 NONE I. CON TRADE
PHENOBARBITAL 130MG AMP 26 0 NONE ZUELLIG PHARMA INC. 22 NONE 4
200 NONE ZUELLIG PHARMA INC.
VALIUM 10MG AMP 130 366 NONE 240
60 NONE I. CON TRADE
EPHEDRINE 50MG AMP 102 100 NONE R-MERCK DRUG 88 NONE 114
FENTANYL PATCH 0 10 NONE I. CON TRADE 2 NONE 8
MORPHINE 16MG AMP 84 0 NONE R-MERCK DRUG 50 NONE 34
MORPHNE 10MG TABLET 1015 0 NONE R-MERCK DRUG 231 NONE 784
MORPHINE 10MG AMP 86 100 NONE R-MERCK DRUG 123 NONE 63
Note: Fill-out all columns. Indicate n/a if not applicable. Indicate no then follows after the last drug entry. Summary Report (January to June or July to December) and Register are to be submitted and presented
respectively not later than 15 days after the covered period. Late submission shall be accompanied by an affidavit stating circumstances of the delay. If report covers more than 1 page, sign all pages.

CERTIFIED TRUE AND CORRECT. FURTHER CERTIFY THAT AFOREMENTIONED END BALANCE TALLIES WITH THE ACTUAL INVENTORY AS OF __
DECEMBER 31,2018

MARIA ZINDA A. MOLINA-MAJOMETANO REV. FR. MICHAEL P. TANGENTE S.V.D.


Printed Name and Signature of Authorized Pharmacist Printed Name, Designation and Signature of Head
1/3/2019
Date Prepared