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

View: CGHS: Instructions for Issuance of Restricted Medicines

Click here to view/download the PDF

[https://cghs.gov.in/showfile.php?lid=6216]

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