Injectable Medication Log Sheet Page 2
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4Order Form For Haloperidol And Fluphenazine Decanoate Injection
Clinic Name: _________________________
Date: _________________________
Requester Name: _____________________
Pharmacy
Clinic
Quantity
Quantity
Staff
Staff
Drug Name & Strength
Requested
Provided
Signature
Signature
Haloperidol Decanoate 50mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
Haloperidol Decanoate 100mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
Fluphenazine Decanoate 25mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
•Maximum Supply to be Stocked is six vials of each of the above depending on your usage.
•Keep log on file for 1 year at clinic.
•Please reorder when you have two vials on hand.
Injectable Med Requisition Form
rev 3/01/07
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Parent category: Medical