Dr. D.Y Patil Pratishthan’s
Dr. D.Y Patil College of Pharmacy Akurdi, Pune – 411044
Department of Pharmacy Practice (Pharm. D.)
DIC Home
Register
Guidelines
About Us
Clear All
Drug Information Requesting Form
Name:
Designation:
Dept/Unit:
Contact No:
Mode of Communication:
--Select--
Phone
Email
In-Person
Patient Information
Age:
Gender:
--Select--
Male
Female
Other
Diagnosis:
Current Medication:
Relevant History:
Select query categories
Select all
Clear
Drug Interaction
Adverse Drug Reaction
Dose Adjustment
Therapeutic Interchange
Polypharmacy Review
OTC Counseling
Herb-Drug Interaction
Other
(optional)
Specific Question/Query:
Level of Urgency:
--Select--
Routine (Reply within 24-48 hours)
Urgent (Reply within 2-4 hours)
Emergency
Date & Time of Request:
Sign (optional):
For DIC Use Only
Received By:
Mode of Communication:
Date/Time Assured:
Answered By:
Sources of Information:
Remark:
Submit