CGHS: Utilization Certificate Form: Required for Issuance of Restricted Medicine from CGHS

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Utilization Certificate Form: Required for Issuance of Restricted Medicine from CGHS

Utilization Certificate

This is to certify that … … … … … … … … … … … … … … (Name of Medicines, quantity, dose, frequency) … … … … … … … … … … … … … issued to … … … … … … … … … … … … … … (Name & Token No of Patient /Name of Dispensary) issued on… … … … … … … … … (Date of issue) has been utilized /will be utilized by(Date) … … … … … … … If required empty strips/vials will be submitted.

Signature of Patient Token No: Address & Telephone No

Signature of the Specialist/ CMO Date:- Stamp

Counter Signature of CMO I/C WC with Stamp