Purchase Request: Cagayan Valley Medical Center Cagayan Valley Medical Center

Republic of the Philippines
Department of Health
CAGAYAN VALLEY MEDICAL CENTER
Dalan Na Pagayaya, Regional Government Center
Carig Sur, Tuguegarao City, Cagayan
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : PR No.: 2017-08 Date:
Responsibility Center Code :
Stock/ ___________
Property Unit Item Description Quantity Unit Cost
No.
Purpose:
Requested by: Approved by:

Signature :
Printed GLENN MATHEW G. BAGGAO, MD, MHA, MSN,
Name : MELITA T. TAGUIBAO, RN, MAED, DPM FPSMS
Designation : Chief Administrative Officer Medical Center Chief II
PR-003-1
ER
nter
: __________________
Total Cost
oved by:
ATHEW G. BAGGAO, MD, MHA, MSN,

FPSMS
Medical Center Chief II
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Clinical Laboratory PR No.: 2017-08 Date:
Stock/ ___________
No.
pc AIR CONDITION, SPLIT TYPE, FLOOR MOUNTED 1

>Non Inverter
>Volts - 220V/single phase/60HZ
>with wireless remote control
>60 A Circuit braker NEMA 3 R
>R-22
>with installation and wirings
pc AIR CONDITION, SPLIT TYPE, WALL MOUNTED 1
>Inverter Type
>capacity = 2HP
>Volts - 220-230V/60HZ
> with installation and wirings
pc AIR CONDITION, SPLIT TYPE, WALL MOUNTED 1
>Non Inverter
>Volts - 220V/single phase/60HZ
>R-22
>with installation and wirings
********WITH IRS
TOTAL:
Purpose: FOR CVMC LABORATORY USE = For Purchase and installation

Signature :
Designation Chief Administrative Officer Medical Center Chief II
:
PR-003-1
TER
Center
r: __________________
Sept. 5 2017
Total Cost
-
1.00
-
-
-
-
-
-
1.00
-
-
-
-
-
1.00
-
-
-
-
-
-
3.00
roved by:

FPSMS
PR-003-1

PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Nursing Office PR No.: 2017-11-036-OS Date: 20-Nov-17
Stock/ ___________
Property Unit Item Description Quantity Unit Cost Total Cost
No.
pcs PATIENT'S GOWN (ADULT)
EXTRA LARGE 300 ₱385.00 115,500.00
LARGE 500 ₱375.00 187,500.00
MEDIUM 250 ₱375.00 93,750.00
SMALL 250 ₱375.00 93,750.00
60-80% Cotton, 20-30% polyester
smooth, soft textured resistant to tear
Customized full linen print (LOGO with the name
Cagayan Valley Medical Center - see attached
sample)
Excellent Color fastness after repeated washing
Plastic Sew-on Snaps (Green) on openings
with Velcro snap finish on shoulder opening
pcs PATIENT'S GOWN (PEDIA)
LARGE 100 ₱285.00 28,500.00
MEDIUM 100 ₱285.00 28,500.00
SMALL 50 ₱285.00 14,250.00
smooth, soft textured resistant to tear
Color: Green, Accent 6, Lighter 80%
Customized full linen print (LOGO with the name
Cagayan Valley Medical Center - see attached
sample)
Excellent Color fastness after repeated washing
Plastic Sew-on Snaps (Green) on openings
with Velcro snap finish on shoulder opening
TOTAL: ₱561,750.00
*************************
BASED ON PPMP 2017
Purpose: FOR ALL WARDS USE

Signature :
Printed
Name :
OLIVIA GONZALES, RN, MSN, MAN GLENN MATHEW G. BAGGAO, MD, MHA, MSN, FPSMS
Designatio Chief Nursing Officer Medical Center Chief II
n:
PR-003-1

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
pcs LAPAROTOMY SHEET 200 ₱480.00 96,000.00
Color: Heavy Oxford Green, Size 160 x 60"
pcs MAYO TABLE COVER 250 ₱145.00 36,250.00
Color Heavy Oxford Green, Size 100 x 82"
pcs MAYO TRAY COVER 250 ₱145.00 36,250.00
Color Heavy Oxford Green, Size 16 x 27.5"
pcs OR TABLE COVER 100 ₱140.00 14,000.00
Color Heavy Oxford Green, Size 60 x 36"
PATIENT'S GOWN (ADULT) (Wrap-around)
pcs EXTRA LARGE 100 ₱385.00 38,500.00
pcs LARGE 100 ₱375.00 37,500.00
pcs MEDIUM 100 ₱375.00 37,500.00
pcs SMALL 100 ₱375.00 37,500.00
smooth, soft textured resistent to tear
Color: Green,, Accent 6, Lighter 80%
Customized full linen print bearing the
(LOGO with name of the hospital- Cagayan
Valley Medical Center)
Excellent Color fastness after repeated wash
TOTAL: ₱333,500.00
*************************
BASED ON PPMP 2017
Signature :
Printed
Name : OLIVIA GONZALES, RN, MSN, MAN GLENN MATHEW G. BAGGAO, MD, MHA, MSN, FPSMS
n:
PR-003-1

PURCHASE REQUEST
60-80% Cotton, 20-30%
Fund Cluster: __________________
polyester
smooth, soft textured resistent
Office/Section : Nursing Office PR No.: 2017-11-038-OS Date: 20-Nov-17 to tear
Responsibility Center Code : Color: Green,, Accent 6, Lighter
___________ 80%
Customized full linen print
Stock/
Property Unit Item Description Quantity Unit Cost Total Cost bearing
(LOGOthe
with name of the hospital-
No. Cagayan
pcs OPERATING GOWN Valley Medical Center)
Excellent Color fastness after
LARGE 150 ₱385.00 57,750.00 repeated wash
MEDIUM 300 ₱385.00 115,500.00
Heavy Oxford Green with
pcs PILLOW 500 ₱150.00 75,000.00
Hypoallergenic, Size: Regular (28 x 17.5") Size: 28in x 17.5in (LxW)
pcs PILLOW CASE 500 ₱100.00 50,000.00
60-80% cotton, 20-30% polyester
Size: 28in x 17.5in (LxW)
Color: Green, Accent 6, Lighter 40%
pcs TOWELS 500 ₱25.00 12,500.00
Color: Green, Size: 28 x 22 inches
pcs WOOL BLANKET 30 ₱250.00 7,500.00
Wool made
Size: 80in x 60in (LxW)
Color: Green, Accent 6, Darker 25%
TOTAL: ₱318,250.00
*************************
BASED ON PPMP 2017

Signature :
Printed
Name :
n:
PR-003-1

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
pcs EYE SHEET, Peach Twill 250 ₱140.00 35,000.00
60-80% Cotton, 20-30%
Color: Green, Size: 28 x 22 inches (LxW)
polyester
smooth, soft textured resistent
Hole Diameter at the center: 7 inches
to tear
Color: Green,, Accent 6, Lighter
pcs FITTED SHEET 80% Customized full linen print
60-80% cotton, 20-30% polyester
bearing
(LOGOthe with name of the hospital-
Color: White Cagayan
60-80% Cotton, 20-30% polyester Valley Medical Center)
Excellent Color fastness after
repeated wash
Color: Green, Accent 6, Darker 50%
Mattres Dimensions to cover: (LxWxH)
77in x 34.5in x 4in (for Adult Bed) 600 ₱284.00 170,400.00
71in x 28in x 3in (for Pedia Bed) 100 ₱284.00 28,400.00
70in x 25in x 3in (for Strecher Bed) 25 ₱284.00 7,100.00 size: 100in x 60in (Lx W)
72in x 22in x 2in (for Roller Stretcher Bed) 25 ₱284.00 7,100.00
pcs FLAT SHEET 1000 ₱120.00 120,000.00
size: 100in x 60in (Lx W)
Color: Green,, Accent 6, Lighter 40%
TOTAL: ₱368,000.00
*************************
BASED ON PPMP 2017

Signature :
Printed
Name :
n:
PR-003-1

PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Nursing Office PR No.: 2017-08 Date: Sept. 5 2017
Stock/ ___________
No.
pcs DIALYSIS CHAIR COVER 15 15.00
60-80% cotton, 20-30% polyester -
Color: Green -
(LOGO with name of the hospital - -
Cagayan Valley Medical Center) -
with Chair Cover number -
size: To measure actual Dialysis Chair -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
TOTAL: ₱15.00

Signature :
Printed
Name : OLIVIA GONZALES, RN, MSN, MAN GLENN MATHEW G. BAGGAO, MD, MHA, MSN, FPSMS
n:
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : ADMITTING AND INFO PR No.: Date:
Stock/ ___________
No.
PC PRINTER (Laser-monochrome, up to 18 PPM 3 ₱3,250.00
WIFI, USB, 400x600x2 DPI, Black Housing
Control Panel with 3-led indicator lights
(wireless attention ready) 2 buttons
(wireless, cancel)
TOTAL:
Purpose: FOR ADMITTING USE

Signature :
PR-003-1
ER
Center
: __________________
September 22, 2017
Total Cost
9,750.00
₱9,750.00
oved by:

FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Emergency Dept. PR No.: Date:
Stock/ ___________
No.
Set ECG MACHINE CABLE of EDAN SE-3 4 ₱4,500.00
TOTAL:
Purpose: FOR EMERGENCY DEPARTMENT USE

Signature :
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
18,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱18,000.00
oved by:

FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Pyschiatry PR No.: Date:
Stock/ ___________
No.
Pcs Laptop 2 ₱25,000.00
Atleast 1TB hard drive
Core i3
12 Inches monitor
with bag
Pcs Printer (Monochrome) 3 ₱7,000.00
Pcs Computer Desktop 3 ₱20,000.00
with table
with complete accessories
core i3
Atleast 2TB hard drive
Atleast 15inches monitor
Atleast 2gb RAM
TOTAL:
Purpose: For Psychiatry Use

Signature :

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Pyschiatry Beds 150 ₱8,000.00
TOTAL:

Signature :
Name :
MELITA T. TAGUIBAO, RN, MAED, DPM FPSMS

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Roller Stretcher 1 ₱165,000.00
1900Lx750Wx650mmH
Better stainless steel
Better 3 crank model adjustment
Folding side rails with push bar handle
Better oxygen tank holder with shelve beneath
comply backrest and knee or foot height
IV pole with 2 hooks and pole socket all corners
3'4" uratex mattress reterdant foam with leather cover
Anti-fungus and water proof
12 months warranty factory defect
Lifetime service warranty
TOTAL:
Signature :

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Sunction Machine (Heavy Duty) 1 ₱90,000.00
>High Capacity with wheels(1liter)
>1.5L capacity autoclavable bottle with extra
bottle, AVR inclusve with trolley, lockable
wheels
>220-230 voltage, 50-60Hz, power consumption
175 watts
>Up to 1.85L per minute sunction performance
TOTAL:

Signature :

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Weighing Scale 3 ₱5,000.00
>With weight rod for adult
>Capacity 40lbsx40z(180kgx100g)
>Height rod Measures: 30-78inch(76-198cm)
>Scale height: 59 inches (1.5m)
TOTAL:

Signature :

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Sphymomanometer 4 ₱1,500.00
>With Stand
>With Adult cuff
>Non-mecurial
Pcs Stethoscope 4 ₱500.00
>Tunable diaphragm
>Nonchill rim and diaphragm
>Low and high frequency acoustic sensitivity
>Durable tubing
>Double-leaf binaural spring inside the tubing
>Chestpiece: Dual head nonchill rim and
diaphragm
>Diaphragm: Tunable diaphragm
>Binaural: Dual-leaf spring encased at 15° angle
>Operating temperature range: 0°C-40°C
(32°F - 104°F)
>Operating humidity: Less than 95% RH
>Storage temperature range:-10°C - 50°C
(14°F - 122°F)
>Storage humidity: Less than 95% RH
TOTAL:

Signature :
Name : MELITA T. TAGUIBAO, RN, MAED, DPM
FPSMS

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Nebulizer Machine 3 ₱2,000.00
>Heavy duty
>Single phase
>230 volts 60, Hz
>portable
TOTAL:

Signature :
FPSMS

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Grass Cutter (2stroke grass cutter with metal 4 ₱6,400.00
blade or nylon blade)
>Engine type: 2 stroke, single cylinder
>Displacement 22cc
>Related power output: 1.4 kw
>Fuel tank capacity: 700ml
>Engine weight: 7.8kg
>Two cycle oil/gasoline mixing ratio: 1:25
>With complete accessories
TOTAL:

Signature :
Name :

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Resuscitator (Ambubag) Adult 1 ₱1,000.00
>Weighing approx. 415 grams
>Made of Silicon Materials
>Excellent bag re-expansion equipped
>With pressure relief at 40cm water with
over riding mechanism
>Bag volume: 1,300ml
>Approx. dimensions: 75x135mm
Pcs Ambubag Mask 1 ₱1,000.00
>Should have silicon rubber below withstand
>Should provide with autoclavable face mask
>Should have a bag volume of 1700ml.
and a variation of ± 100ml.
will be accepted
>Should have an expiratory resistance of 2.2cms of water
>Should have controlled flow rates and
ventilation, and with reduced airway pressure
TOTAL:

Signature :
FPSMS

PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Emergency Lights 6 ₱2,500.00
TOTAL:

Signature :
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
50,000.00
-
-
-
-
21,000.00
60,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱131,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
1,200,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱1,200,000.00
oved by:
FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
165,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱165,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
90,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱90,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
15,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱15,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
6,000.00
-
-
-
2,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱8,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
6,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱6,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
25,600.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱25,600.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
1,000.00
-
-
-
-
-
-
-
1,000.00
-
-
-
-
-
-
-
-
-
-
-
-
₱2,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
15,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱15,000.00
oved by:

FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Glucometer 1 ₱5,000.00
>Should have reading range/linearity from
20 to 600mg/dl 4
>Should have a maximum reading time
of less than 10 secs
>Should use a minimum blood sample
less than 1.5ul
>Should have measuring unit in mg/dl
>Should have wide operating temperature
>Should have LCD Display
>Battery should be replaceable
without using any tools
Pcs Glucometer Strip 1000 ₱20.00
>Should be able to use capillary blood samples
>Should have a maximum 4 months shelf
life after opening the strip vial
>All strips should have atleast 1 year
expiry date from the date of supply.
>50 strips should be supplied along with the equipment
>Strips should be available in the local market
TOTAL:

Signature :
MELITA T. TAGUIBAO, RN, MAED, DPM
Name : FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Electric Barber Razor Clipper 8 ₱2,000.00
>Memory SafetyLock System
>Ultra sharp blades for precision cutting
>Fully washable
>DualBattery system, Designed to perform
>LED charging indicator
>Automatic worldwide voltage adjustment
TOTAL:

Signature :
Name :
FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Uninterupted Power Supply (UPS) 3 ₱4,000.00
atleast 200-240 volts
capacity: atleast 800VA
TOTAL:

Signature :
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Pcs Water Purifier
Frequency: 50 Hz
Voltage: 220-240 V
Water Flow rate: max 2 l/min
Power rating: 25 W
Max input water temperature: 45°C
Max input water pressure: 2.0 bar
Min input water pressure: 0.5 bar
Min input water temperature: 5°C
Product Weight: 3.5 kg
Product Dimensions: 287Lx156Wx422mmH
PLS UV Lamp
TOTAL:





PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
5,000.00
-
-
-
-
-
-
-
-
-
-
-
20,000.00
-
-
-
-
-
-
-
-
₱25,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
16,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱16,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
12,000.00
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱12,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Sept. 22 2017
Total Cost
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
₱0.00
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
ER
Center
PURCHASE REQUEST
METRODRUG Fund Cluster: __________________
Office/Section : PHARMACY SECTION PR No.: 2017-08 Date:
Stock/ ___________
No.
Docetaxel 20mg/0.5ml, 0.5ml (IV infusion),
DM-442 vial 50 ₱820.00
VEXDO 20
DM-443 Docetaxel 80mg/ml, 2ml (IV infusion), VEXDO 80
vial 50 ₱3,465.00
********************
Winning Bidder, Public Bidding C.Y. 2017
TOTAL
Purpose: FOR CVMC PHARMACY - CLUSTER IV (ANTINEOPLASTICS AND IMMUNOSUPPRESIVES)

Signature :
Name :
PURCHASE REQUEST
RBC-MDC CORPORATION Fund Cluster: __________________

Stock/ ___________
No.
Iopamidol 755mg/ml equiv. to 370mg iodine,50ml vial,
DM-331 vial SCANLUX
500 ₱1,098.00
********************
TOTAL
Purpose: FOR CVMC PHARMACY - CLUSTER III

Signature :
Name :
PURCHASE REQUEST
ZUELLIG PHARMA Fund Cluster: __________________
Stock/ ___________
No.
DM-186 ampule Isosorbide Dinitrate 1mg/ml, 10ml amp (IV), ISOKET 500 ₱533.99
DM-411 ampule Somatostatin 3mg amp/vial (IV, IV infusion), GENERIC 50 ₱4,796.10
Valproate disodium/ Valproic Acid 250mg/tab. (as disodium
DM-425 tablet salt or as valproic acid), EPIVAL 5000 ₱29.00
********************
TOTAL

Signature :
Name :
PURCHASE REQUEST
DYNASTY PHARMACEUTICALS Fund Cluster: __________________
Stock/ ___________
No.
Tramadol 50mg, 2ml (IM,IV,SC) capsule (as HCl),
DM-423 capsule DYNATRAM 500 ₱10.00
********************
TOTAL

Signature :
FPSMS
PURCHASE REQUEST
OXFORD Fund Cluster: __________________
Stock/ ___________
No.
DM-428 bot Zinc 10mg/ml drops, IMMUZINE 50 ₱40.00
DM-429 bot Zinc 20mg/5ml syrup, IMMUZINE 50 ₱41.00
********************
TOTAL

Signature :
Name :

PURCHASE REQUEST
SANNOVEX PHARMA Fund Cluster: __________________
Stock/ ___________
No.
Hydrocortisone 125mg/ml, 2ml vial (IV) (as Sodium
DM-178
vial Succinate) act o vial, HYDROVEX 1000 ₱140.00
Hydrocortisone 50mg/ml, 2ml vial (IV) (as Sodium
DM-179 vial Succinate) act o vial, HYDROVEX 2000 ₱75.00
********************
TOTAL

Signature :
Name :

PURCHASE REQUEST
GENACE PHARMA Fund Cluster: __________________
Stock/ ___________
No.
DM-459 tab Tamoxifen 20mg tablet (as Citrate), TAMOXIGEN 20 1000 ₱6.50
********************
TOTAL

Signature :
Name :

PURCHASE REQUEST
VIZCARRA Fund Cluster: __________________
Stock/ ___________
No.
DM-323 vial Human Albumin 20%, 50ml, ALBUMAX 200 ₱2,175.00
********************
TOTAL

Signature :
Name :
PR-003-1
ER
Center
: __________________
Total Cost
41,000.00
173,250.00
-
-
-
-
-
₱214,250.00
NOSUPPRESIVES)
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
549,000.00
-
-
-
-
-
-
-
-
549,000.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
266,995.00
239,805.00
145,000.00
-
-
-
-
-
-
651,800.00
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
5,000.00
-
-
-
-
-
-
-
-
5,000.00
oved by:

FPSMS
ER
Center
: __________________
Total Cost
2,000.00
2,050.00
-
-
-
-
-
-
-
4,050.00
oved by:
FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
140,000.00
150,000.00
-
-
-
-
-
₱290,000.00
NOSUPPRESIVES)
oved by:
FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
6,500.00
-
-
-
-
-
₱6,500.00
NOSUPPRESIVES)
oved by:
FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
435,000.00
₱435,000.00
NOSUPPRESIVES)
oved by:
FPSMS
PURCHASE REQUEST
Fund Cluster: __________________
Office/Section : Pharmacy Section PR No.: 2017-08 Date:
Stock/ ___________
No.
vial Cefazolin 500mg vial (IM,IV) (as Sodium salt) 500 ₱59.35
vial Ciprofloxacin 2mg/ml, 100ml vial (as Lactate) IV infusion 500 ₱26.94
capsule Clindamycin 150mg/ml, 4ml ampule (IM,IV) (as PO4) 1000 ₱150.63
capsule Clindamycin HCl 300mg capsule 2000 ₱3.61
suspensio Erythromycin 200mg/5ml granules/powder for suspension
n 60ml (as Ethyl Succinate) 50 ₱57.24
tablet Erythromycin 500mg tab. (as Stearate) 500 ₱5.36
amp/vial Gentamycin 40mg/ml, 2ml amp/vial (IM,IV) (as SO4) 1000 ₱4.41
suspensio
n
Mebendazole 100mg/5ml suspension 30ml 50 ₱21.42
tablet Mebendazole 500mg tablet/chewable tablet 100 ₱16.74
vial Ofloxacin 2mg/ml, 100ml vial (Iv infusion) 50 ₱512.17
tablet Ofloxacin 400mg tablet 500 ₱10.18
capsule Oseltamivir 75mg capsule (as Phosphate) 200 ₱44.19
suspensio Oxantel Pyrantel (100mg Oxantel + 100mg Pyrantel)/5ml
n susp. 10ml (as Embonate)
50 ₱70.04
vial Vancomycin 500mg vial (IV) (as HCl) 500 ₱211.56
TOTAL
Purpose: FOR CLUSTER I

Signature :
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
ampule Aminophylline 25mg/ml, 10ml ampule (IV) 100 ₱23.15
tablet Amlodipine 10mg/tab. (as Besylate) 2000 ₱4.82
ampule Anti-Tetanus Serum (equine) 1,500IU/ml, 1ml amp/vial (IM) 2000 ₱28.23
tablet Atenolol 100mg tablet 500 ₱7.12
tablet Clonidine 75mcg tablet (as HCl) 500 ₱19.68
tablet Clopidogrel 75mg tablet 2000 ₱3.73
tablet Dexamethasone 4mg tablet 500 ₱22.92
Dexamethasone 4mg/ml, 2ml amp/vial (IM,IV) (asSodium
tablet Phosphate)
1000 ₱42.43
tablet Diltiazem 60mg tablet( as Hydrochloride) 1000 ₱41.28
tablet Dydrogesterone 10mg/tablet 1000 ₱56.24
tablet Fenofibrate 200mg tablet 1000
p. syringe Fondaparinux 2.5mg/0.5ml solution (as Sodium salt) 400
patch Glyceryl Trinitrate (Nitroglycerin) 5mg patch 100
nebule Ipratropium + Salbutamol UDV 2.5ml/ unit dose 6000
tablet Isosorbide dinitrate 10mg tablet 500
tablet Isosorbide dinitrate 5mg tablet SL 1000
tablet Levothyroxine 100mcg/tab (as Anhydrous Sodium) 1000
tablet Medroxyprogesterone Acetate 5mg tablet 200
tablet Metformin 500mg tab/film coated tab (as HCl) 3000
tablet Nifedipine 30mg MR tablet 1200
tablet Nimodipine 30mg tablet 1200
TO PAGE 2
Purpose:

Signature :
Name : FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
FROM PAGE 1
bottle Prednisone 10mg/5ml suspension, 60ml 50
tablet Spironolactone 100mg tablet 1000
tablet Spironolactone 50mg tablet 1000
ampule Tetanus Toxoid 0.5ml ampule (IM) 1500
capsule Tranexamic Acid 100mg/ml, 5ml ampule (IM,IV) 2000
capsule Tranexamic Acid 500mg capsule 2000
ampule Verapamil 2.5mg/ml, 2ml ampule (IV) (as Hydrochloride) 100
tablet Warfarin 2.5mg tablet 500
*****************************************************
TOTAL
Purpose:

Signature :
Name :
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PURCHASE REQUEST
Fund Cluster: __________________
Stock/ ___________
No.
Purpose:

Signature :
Name :
FPSMS
:
PR-003-1
ER
Center
: __________________
Total Cost
29,675.00
13,470.00
150,630.00
7,220.00
2,862.00
2,680.00
4,410.00
1,071.00
1,674.00
25,608.50
5,090.00
8,838.00
3,502.00
105,780.00
362,510.50
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS
PR-003-1
ER
Center
: __________________
Total Cost
oved by:

FPSMS

Purchase Request: Cagayan Valley Medical Center Cagayan Valley Medical Center

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Republic of the Philippines

Requested by: Approved by:

ATHEW G. BAGGAO, MD, MHA, MSN,

pc AIR CONDITION, SPLIT TYPE, FLOOR MOUNTED 1

Requested by: Approved by:

ATHEW G. BAGGAO, MD, MHA, MSN,

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Requested by: Approved by:

ATHEW G. BAGGAO, MD, MHA, MSN,

Requested by: Approved by:

ATHEW G. BAGGAO, MD, MHA, MSN,

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

Republic of the Philippines

Requested by: Approved by:

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

Requested by: Approved by:

Requested by: Approved by:

Requested by: Approved by:

Republic of the Philippines

Republic of the Philippines

Republic of the Philippines

Republic of the Philippines

Republic of the Philippines

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

ATHEW G. BAGGAO, MD, MHA, MSN,

Purpose: FOR CVMC PHARMACY - CLUSTER IV (ANTINEOPLASTICS AND IMMUNOSUPPRESIVES)