DAFTAR OBAT MENGANDUNG PREKURSOR

Bentuk dan
No Nama Obat Zat Aktif Prekursor Satuan
Kekuatan Sediaan
1 Actifed Cough Plus Suppressant 60 ml Pseudoephedrine HCl Syrup & 30 mg Botol
2 Actifed Cough Plus Expectorant 60 ml Pseudoephedrine HCl Syrup & 30 mg Botol
3 Actifed Syrup 60 ml Pseudoephedrine HCl Syrup & 30 mg Botol
4 Allerin Expectorant 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
5 Alpara Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
6 Alpara Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
7 Anakonidin OBH 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
8 Anakonidin OBH 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
9 Anakonidin Syrup 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
10 Anakonidin Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
11 Anaton Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
12 Bodrexin Flu & Batuk Syrup 56 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
13 Bodrexin Pilek Alergi Syrup 56 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
14 Bronchitin Expectorant 50 ml Ephedrine HCl Syrup & 8 mg Botol
15 Bufagan Expectorant 60 ml Ephedrine HCl Syrup & 2.5 mg Botol
16 Bufakris Syrup 60 ml Ephedrine HCl Syrup & 4.17 mg Botol
17 Calortusin Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.75 mg Botol
18 Calortusin Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
19 Citocetine Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
20 Colfin Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
21 Coparcetine Syrup 60 ml Ephedrine HCl Syrup & 4 mg Botol
22 Coparcetine Tablet Ephedrine HCl Tablet & 8 mg Box
23 Decolgen Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
24 Decolgen Tablet Phenylpropanolamine HCl Tablet & 12.5 mg Box
25 Decolsin Capsule Pseudoephedrine HCl Kapsul & 30 mg Box
26 Decolsin Syrup 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
27 Dextral Forte Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
28 Dextral Syrup 60 ml Phenylpropanolamine HCl Syrup & 15 mg Botol
29 Dextral Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
30 Etaflusin Syrup 60 ml Ephedrine HCl Syrup & 3 mg Botol
31 Flucadex Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
32 Flucadex Syrup Phenylpropanolamine HCl Syrup & 7.5 mg Botol
33 Fludane Forte Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
34 Fludane Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
35 Fludane Plus Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
36 Fludane Plus Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
37 Fludane Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
38 Flumin Plus Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
39 Flumin Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
40 Flutamol Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
41 Flutamol Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
42 Flutop C Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
43 Hufagrip Forte Tablet Ephedrine HCl Tablet & 5 mg Box
44 Hufagrip Pilek Syrup 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
45 Hufagrip Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
46 Hufagrip BP Syrup 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
47 Intunal Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
48 Intunal Forte Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
49 Intunal Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
50 Inza Kaplet Pseudoephedrine HCl Kaplet & 30 mg Box
51 Millsen Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
52 Mixagrip Flu & Batuk Kaplet Pseudoephedrine HCl Kaplet & 30 mg Box
53 Molexflu Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
54 Molexflu Tablet Phenylpropanolamine HCl Tablet & 12.5 mg Box
55 Nalgestan Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
56 Neo Napacin Tablet Ephedrine HCl Tablet & 12.5 mg Box
57 Neozep Forte Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
58 OBH Combi Batuk Flu Menthol 60ml Ephedrine HCL Sirup & 2.5 mg Botol
59 OBH Combi Batuk Flu Jahe 60ml Ephedrine HCL Sirup & 2.5 mg Botol
60 OBH Combi Batuk Flu Madu 60ml Ephedrine HCL Sirup & 2.5 mg Botol
61 OBH Combi Batuk Flu Menthol 100ml Ephedrine HCL Sirup & 2.5 mg Botol
62 OBH Combi Batuk Flu Jahe 100ml Ephedrine HCL Sirup & 2.5 mg Botol
63 OBH Combi Batuk Flu Anak Apel 60ml Pseudoephedrine HCL Sirup & 7.5 mg Botol
64 OBH Combi Batuk Flu Anak Orange 60ml Pseudoephedrine HCL Sirup & 7.5 mg Botol
65 OBH Combi Batuk Flu Anak Strawberry 60ml Pseudoephedrine HCL Sirup & 7.5 mg Botol
66 OBH Combi Batuk Flu Anak Madu 60ml Pseudoephedrine HCL Sirup & 7.5 mg Botol
67 Paracetin Syrup 60 ml Ephedrine HCl Syrup & 3 mg Botol
68 Paratenza Syrup 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
69 Paratusin Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
70 Paratusin Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
71 Pimtrakol Cherry Syrup 60 ml Ephedrine HCl Syrup & 2.5 mg Botol
72 Pimtrakol Plus Syrup 60 ml Ephedrine HCl Syrup & 2.5 mg Botol
73 Poncolin Syrup 60 ml Ephedrine HCl Syrup & 8 mg Botol
74 Siladex Cough & Cold 30 ml Ephedrine HCl Syrup & 15 mg Botol
75 Siladex Cough & Cold 60 ml Ephedrine HCl Syrup & 15 mg Botol
76 Tera F Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
77 Termorex Plus Syrup 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
78 Termorex Plus Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
79 Thymcal Syrup 100 ml Ephedrine HCl Syrup & 10 mg Botol
80 Triaminic Batuk & Pilek 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
81 Triaminic Ekspektoran 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
82 Triaminic Pilek 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
83 Neo Triaminic Drops 10 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
84 Ultraflu Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
 DAFTAR OBAT MENGANDUNG PREKURSOR
No Nama Obat Zat Aktif Prekursor
1 Actifed Cough Plus Suppressant 60 ml Pseudoephedrine HCl
2 Actifed Cough Plus Expectorant 60 ml Pseudoephedrine HCl
3 Actifed Syrup 60 ml Pseudoephedrine HCl
4 Allerin Expectorant 60 ml Pseudoephedrine HCl
5 Alpara Syrup 60 ml Phenylpropanolamine HCl
6 Alpara Kaplet Phenylpropanolamine HCl
7 Anakonidin OBH 30 ml Pseudoephedrine HCl
8 Anakonidin OBH 60 ml Pseudoephedrine HCl
9 Anakonidin Syrup 30 ml Pseudoephedrine HCl
10 Anakonidin Syrup 60 ml Pseudoephedrine HCl
11 Anaton Syrup 60 ml Phenylpropanolamine HCl
12 Bodrexin Flu & Batuk Syrup 56 ml Pseudoephedrine HCl
13 Bodrexin Pilek Alergi Syrup 56 ml Pseudoephedrine HCl
14 Bronchitin Expectorant 50 ml Ephedrine HCl
15 Bufagan Expectorant 60 ml Ephedrine HCl
16 Bufakris Syrup 60 ml Ephedrine HCl
17 Calortusin Syrup 60 ml Phenylpropanolamine HCl
18 Calortusin Tablet Phenylpropanolamine HCl
19 Citocetine Syrup 60 ml Pseudoephedrine HCl
20 Colfin Syrup 60 ml Phenylpropanolamine HCl
21 Coparcetine Syrup 60 ml Ephedrine HCl
22 Coparcetine Tablet Ephedrine HCl
23 Decolgen Syrup 60 ml Pseudoephedrine HCl
24 Decolgen Tablet Phenylpropanolamine HCl
25 Decolsin Capsule Pseudoephedrine HCl
26 Decolsin Syrup 60 ml Pseudoephedrine HCl
27 Dextral Forte Kaplet Phenylpropanolamine HCl
28 Dextral Syrup 60 ml Phenylpropanolamine HCl
29 Dextral Kaplet Phenylpropanolamine HCl
30 Etaflusin Syrup 60 ml Ephedrine HCl
31 Flucadex Kaplet Phenylpropanolamine HCl
32 Flucadex Syrup Phenylpropanolamine HCl
33 Fludane Forte Kaplet Phenylpropanolamine HCl
34 Fludane Kaplet Phenylpropanolamine HCl
35 Fludane Plus Kaplet Phenylpropanolamine HCl
36 Fludane Plus Syrup 60 ml Phenylpropanolamine HCl
37 Fludane Syrup 60 ml Phenylpropanolamine HCl
38 Flumin Plus Syrup 60 ml Phenylpropanolamine HCl
39 Flumin Tablet Phenylpropanolamine HCl
40 Flutamol Syrup 60 ml Phenylpropanolamine HCl
41 Flutamol Kaplet Phenylpropanolamine HCl
42 Flutop C Syrup 60 ml Phenylpropanolamine HCl
43 Hufagrip Forte Tablet Ephedrine HCl
44 Hufagrip Pilek Syrup 60 ml Pseudoephedrine HCl
45 Hufagrip Syrup 60 ml Pseudoephedrine HCl
46 Hufagrip BP Syrup 60 ml Pseudoephedrine HCl
47 Intunal Kaplet Phenylpropanolamine HCl
48 Intunal Forte Kaplet Phenylpropanolamine HCl
49 Intunal Syrup 60 ml Phenylpropanolamine HCl
50 Inza Kaplet Pseudoephedrine HCl
51 Millsen Syrup 60 ml Phenylpropanolamine HCl
52 Mixagrip Flu & Batuk Kaplet Pseudoephedrine HCl
53 Molexflu Syrup 60 ml Phenylpropanolamine HCl
54 Molexflu Tablet Phenylpropanolamine HCl
55 Nalgestan Tablet Phenylpropanolamine HCl
56 Neo Napacin Tablet Ephedrine HCl
57 Neozep Forte Tablet Phenylpropanolamine HCl
58 OBH Combi Batuk Flu Menthol 60ml Ephedrine HCL
59 OBH Combi Batuk Flu Jahe 60ml Ephedrine HCL
60 OBH Combi Batuk Flu Madu 60ml Ephedrine HCL
61 OBH Combi Batuk Flu Menthol 100ml Ephedrine HCL
62 OBH Combi Batuk Flu Jahe 100ml Ephedrine HCL
63 OBH Combi Batuk Flu Anak Apel 60ml Pseudoephedrine HCL
64 OBH Combi Batuk Flu Anak Orange 60ml Pseudoephedrine HCL
65 OBH Combi Batuk Flu Anak Strawberry 60ml Pseudoephedrine HCL
66 OBH Combi Batuk Flu Anak Madu 60ml Pseudoephedrine HCL
67 Paracetin Syrup 60 ml Ephedrine HCl
68 Paratenza Syrup 60 ml Pseudoephedrine HCl
69 Paratusin Syrup 60 ml Pseudoephedrine HCl
70 Paratusin Tablet Phenylpropanolamine HCl
71 Pimtrakol Cherry Syrup 60 ml Ephedrine HCl
72 Pimtrakol Plus Syrup 60 ml Ephedrine HCl
73 Poncolin Syrup 60 ml Ephedrine HCl
74 Siladex Cough & Cold 30 ml Ephedrine HCl
75 Siladex Cough & Cold 60 ml Ephedrine HCl
76 Tera F Kaplet Phenylpropanolamine HCl
77 Termorex Plus Syrup 30 ml Pseudoephedrine HCl
78 Termorex Plus Syrup 60 ml Pseudoephedrine HCl
79 Thymcal Syrup 100 ml Ephedrine HCl
80 Triaminic Batuk & Pilek 60 ml Pseudoephedrine HCl
81 Triaminic Ekspektoran 60 ml Pseudoephedrine HCl
82 Triaminic Pilek 60 ml Pseudoephedrine HCl
83 Neo Triaminic Drops 10 ml Pseudoephedrine HCl
84 Ultraflu Kaplet Phenylpropanolamine HCl
Colfin Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol
Hufagrip Forte Tablet Ephedrine HCl Tablet & 5 mg Box
Tera F Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
Molexflu Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
Calortusin Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
Molexflu Tablet Phenylpropanolamine HCl Tablet & 12.5 mg Box

Bentuk dan
Nama Obat Zat Aktif Prekursor Satuan Jumlah
Kekuatan Sediaan

Flutop C Syrup 60 ml Phenylpropanolamine HCl Syrup & 3.5 mg Botol

Anakonidin Syrup 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol

Anakonidin Syrup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol

Anakonidin OBH 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol

Anakonidin OBH 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
Bodrexin Flu & Batuk
Pseudoephedrine HCl Syrup & 7.5 mg Botol
Syrup 56 ml
Bodrexin Pilek Alergi Pseudoephedrine HCl Syrup & 7.5 mg Botol
Syrup 56 ml
Termorex Plus Syrup 30
Pseudoephedrine HCl Syrup & 7.5 mg Botol
ml
Termorex Plus Syrup 60
Pseudoephedrine HCl Syrup & 7.5 mg Botol
ml
Ket
1 2 3

4 5 7
 KOP APOTEK/ KLINIK/ RUMAH SAKIT/ TOKO OBAT
SURAT PESANAN OBAT MENGANDUNG PREKURSOR FARMASI
No. SP : Harus diisi dengan lengkap

Yang bertanda tangan di bawah ini

Nama : Harus diisi lengkap dengan gelar
Jabatan : Harus diisi
No. SIPA utk Apotek/ Klinik/ RS, SIPTTK utk Ass.Apoteker di Toko Obat : Harus diisi dengan Lengkap

Mengajukan Pesanan obat mengandung Prekursor Farmasi kepada:

Nama PBF : PT. Triputra Mulia Farmasindo (Harus diisi jangan disingkat)
Alamat : Jl. Pilang Raya No.90 Kedawung - Cirebon (Harus diisi)
Telp : 0231-225540 (Harus diisi)

Jenis Obat mengandung Prekursor Farmasi yang dipesan adalah:

Nama Obat mengandung Prekursor Bentuk dan
No Satuan Jumlah Keterangan
Farmasi Zat Aktif Prekursor Farmasi Kekuatan
Ditulis Ditulis huruf
1 Actifed Plus Cough Suppressent Pseudoephedrine HCl Syrup & 30 mg Botol
angka latin
Ditulis Ditulis huruf
2 Actifed Plus Expectorant Pseudoephedrine HCl Syrup & 30 mg Botol
angka latin
Ditulis Ditulis huruf
3 Actifed Syrup Pseudoephedrine HCl Syrup & 30 mg Botol
angka latin
Ditulis Ditulis huruf
4 Allerin Ekspektoran 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
5 Alpara Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
6 Alpara Sirup 60 ml Phenylpropanolamine HCl Syrup & 3.125 mg Botol
angka latin
Ditulis Ditulis huruf
7 Anakonidin OBH 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
8 Anakonidin OBH 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
9 Anakonidin 30 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
10 Anakonidin 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
11 Bufakris Syrup Ephedrine HCl Syrup & 4.17 mg Botol
angka latin
Ditulis Ditulis huruf
12 Calortusin syrup Phenylpropanolamine HCl Syrup & 3.75 mg Botol
angka latin
Ditulis Ditulis huruf
13 Calortusin Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
angka latin
Ditulis Ditulis huruf
14 Coparcetin Sirup Ephedrine HCl Syrup & 4 mg Botol
angka latin
Ditulis Ditulis huruf
15 Coparcetine Tablet Ephedrine HCl Tablet & 8 mg Box
angka latin
Ditulis Ditulis huruf
16 Decolgen Sirup 60 ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
17 Decolgen Tablet Phenylpropanolamine HCl Tablet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
18 Decolsin Kapsul Pseudoephedrine HCl Kapsul & 30 mg Box
angka latin
Ditulis Ditulis huruf
19 Decolsin Sirup Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
20 Dextral Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
 Ditulis Ditulis huruf
21 Dextral Forte Kapsul Phenylpropanolamine HCl Kapsul & 15 mg Box
angka latin
Ditulis Ditulis huruf
22 Dextral Sirup 60 ml Phenylpropanolamine HCl Syrup & 12.5 mg Botol
angka latin
Ditulis Ditulis huruf
23 Etaflusin Syrup Ephedrine HCl Syrup & 3 mg Botol
angka latin
Ditulis Ditulis huruf
24 Flucadex Sirup 60 ml Phenylpropanolamine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
25 Flucadex Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
angka latin
Ditulis Ditulis huruf
26 Fludane Plus Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
27 Fludane Forte Kapsul Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
28 Flumin Kaplet Phenylpropanolamine HCl Kaplet & 15 mg Box
angka latin
Ditulis Ditulis huruf
29 Flumin Plus Sirup Phenylpropanolamine HCl Syrup & 3.5 mg Botol
angka latin
Ditulis Ditulis huruf
30 Flutop C Sirup Phenylpropanolamine HCl Syrup & 3.5 mg Botol
angka latin
Ditulis Ditulis huruf
31 Hufagrip Batuk Pilek Sirup Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
32 Hufagrip Flu Sirup Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
33 Hufagrip Forte Ephedrine HCl Kaplet & 5 mg Box
angka latin
Ditulis Ditulis huruf
34 Hufagrip Pilek Sirup Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
35 Intunal Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
36 Intunal Sirup Phenylpropanolamine HCl Syrup & 3.5 mg Botol
angka latin
Ditulis Ditulis huruf
37 Intunal Forte Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
angka latin
Tablet & 0.125 Ditulis Ditulis huruf
38 Metilergometrin Maleat Tablet Metilergometrin Maleat Box
mg angka latin
Ditulis Ditulis huruf
39 Molexflu Sirup Phenylpropanolamine HCl Syrup & 3.125 mg Botol
angka latin
Ditulis Ditulis huruf
40 Molexflu Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
41 Nalgestan Phenylpropanolamine HCl Tablet & 15 mg Box
angka latin
Ditulis Ditulis huruf
42 Neo Napacin Ephedrine HCl Tablet & 12.5 mg Box
angka latin
Ditulis Ditulis huruf
43 Neozep Forte Phenylpropanolamine HCl Tablet & 15 mg Box
angka latin
Obh Combi Anak Batuk Plus Flu Ditulis Ditulis huruf
44 Pseudoephedrine HCL Sirup & 7.5 mg Botol
Strawberry angka latin
Obh Combi Anak Batuk Plus Flu Ditulis Ditulis huruf
45 Pseudoephedrine HCL Sirup & 7.5 mg Botol
Apel angka latin
Obh Combi Anak Batuk Plus Flu Ditulis Ditulis huruf
46 Pseudoephedrine HCL Sirup & 7.5 mg Botol
Madu angka latin
Obh Combi Batuk Plus Flu Jahe 100 Ditulis Ditulis huruf
47 Ephedrine HCL Sirup & 2.5 mg Botol
Ml angka latin
Obh Combi Batuk Plus Flu Madu 60 Ditulis Ditulis huruf
48 Ephedrine HCL Sirup & 2.5 mg Botol
Ml angka latin
Obh Combi Batuk Plus Flu Jahe 60 Ditulis Ditulis huruf
49 Ephedrine HCL Sirup & 2.5 mg Botol
Ml angka latin
 Obh Combi Batuk Plus Flu Menthol Ditulis Ditulis huruf
50 Ephedrine HCL Sirup & 2.5 mg Botol
100 Ml angka latin
Obh Combi Batuk Plus Flu Menthol Ditulis Ditulis huruf
51 Ephedrine HCL Sirup & 2.5 mg Botol
60 Ml angka latin
Obh Combi Anak Batuk Plus Flu Ditulis Ditulis huruf
52 Pseudoephedrine HCL Sirup & 7.5 mg Botol
Orange angka latin
Ditulis Ditulis huruf
53 Obh Tropica Extra Menthol 60 ml Ephedrine HCl Sirup & 3 mg Botol
angka latin
Ditulis Ditulis huruf
54 Obh Tropica Extra Menthol 100 ml Ephedrine HCl Sirup & 3 mg Botol
angka latin
Obh Tropica Extra Anak Strawberry Ditulis Ditulis huruf
55 Pseudoephedrine HCl Sirup & 7.5 mg Botol
60 ml angka latin
Ditulis Ditulis huruf
56 Obh Tropica Extra Anak Jeruk 60 ml Pseudoephedrine HCl Sirup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
57 Obh Tropica Plus Menthol 60 ml Ephedrine HCl Sirup & 2.67 mg Botol
angka latin
Ditulis Ditulis huruf
58 Obh Tropica Plus Menthol 100 ml Ephedrine HCl Sirup & 2.67 mg Botol
angka latin
Obh Tropica Plus Anak Strawberry Ditulis Ditulis huruf
59 Pseudoephedrine HCl Sirup & 7.5 mg Botol
60 ml angka latin
Ditulis Ditulis huruf
60 Obh Tropica Plus Anak Jeruk 60 ml Pseudoephedrine HCl Sirup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
61 Paratusin Sirup Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
62 Paratusin Tablet Phenylpropanolamine HCl Tablet & 15 mg Box
angka latin
Ditulis Ditulis huruf
63 Pimtrakol Cherry Ephedrine HCl Syrup & 2 mg Botol
angka latin
Ditulis Ditulis huruf
64 Pimtrakol Lemon Ephedrine HCl Syrup & 2 mg Botol
angka latin
Ditulis Ditulis huruf
65 Siladex Cough & Cold 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
66 Siladex Cough & Cold 30 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
67 Tera-F Phenylpropanolamine HCl Kaplet & 15 mg Box
angka latin
Ditulis Ditulis huruf
68 Termorex Plus 30ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
69 Termorex Plus 60ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka latin
Ditulis Ditulis huruf
70 Triaminic Batuk 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
71 Triaminic Ekspektoran 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin
Ditulis Ditulis huruf
72 Triaminic Pilek 60 ml Pseudoephedrine HCl Syrup & 15 mg Botol
angka latin

Obat mengandung Prekursor Farmasi tersebut akan digunakan untuk memenuhi kebutuhan :
Nama Apotek, Toko Obat, Klinik, Rumah Sakit : Harus diisi dengan lengkap
Alamat Lengkap : Harus diisi dengan Lengkap
No.Ijin Apotek, Toko Obat, Klinik, Rumah Sakit : Harus diisi dengan Lengkap

Tempat, Tanggal - Bulan - Tahun

TTD Apoteker + Cap Apotek, Toko Obat, Klinik, Rumah Sakit

Nama Apoteker diisi lengkap dengan Gelar

SIPA Apoteker (Apotek/Klinik/RS), SIPTTK Ass.Apoteker (Toko Obat)
Note:
Untuk penamaan obat jangan disingkat dan jangan ditulis Actifed merah, actifed hijau, Hufagrip biru, hufagrip kuning,
hufagrip hijau
 Nama Obat mengandung Bentuk dan
No Satuan Jumlah
Prekursor Farmasi Zat Aktif Prekursor Farmasi Kekuatan
Ditulis
1 Molexflu Kaplet Phenylpropanolamine HCl Kaplet & 12.5 mg Box
angka
Ditulis
2 Termorex Plus 30ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka
Ditulis
3 Termorex Plus 60ml Pseudoephedrine HCl Syrup & 7.5 mg Botol
angka
 Keterangan

Ditulis huruf
latin
Ditulis huruf
latin
Ditulis huruf
latin