CME Requisition Form

Date 18/12/18
Pankaj Kumar
Name of Field Staff Head Quarter

Health Point Hospital Bariyatu, Ranchi

Customer Name
Name of Hospital with
/Designation/Depart
Address
ment

80
Bed Strength Name of the Dealer

Infection Control & Prvention of Needle Stic Date of Conducting

Title of CME
CME
No. of Attendees 45 Total Cost involved

Existing Sales
S No. Product Quantity
1 Polyvac 30
2 Polyfusion Set vented 130
3 Novofusion Set 70
4 Photofusion 40
5 nebulizer mask 30
6 polyuro Deluxe 40
7 OXY. Mask 30
8 POLYSUCTION SET 30
9 policizer 10
10 polyway extension 10
11 polyflow with regulator 10
12
13
 Total Existing Sale

Business Expected after CME

Product Quantity
Polyvac 30
Polyfusion Set vented 130
Novofusion Set 70
Photofusion 40
nebulizer mask 30
polyuro Deluxe 40
OXY. Mask 30
POLYSUCTION SET 30
policizer 10
polyway with extension 50
1st Month polyflow regulator 10

Total Rs.Value after 1st Month Post CME

Polyvac 30
Polyfusion Set vented 130
Novofusion Set 70
Photofusion 40
nebulizer mask 30
polyuro Deluxe 40
OXY. Mask 30
2nd Month POLYSUCTION SET 30
policizer 0
polyway with extension 50
 polyflow 20
Polysyte 10
Nelaton cath 100
Ryles tube 50
suction catheter 100

Total Rs.Value after 2nd Month Post CME

Polyvac 30
Polyfusion Set vented 100
Novofusion Set 100
Photofusion 50
Polysyte 30
polyuro-Deluxe 50
P F ADVA 100
POLYSUCTION SET 35
policizer 20
3rd Month polyway extension 15
polyflow 15
Oxygen Mask 35
Neulizer Mask 35
Nelaton cath 100
Ryles tube 50
suction catheter 200

Total Rs.Value after 3rd Month Post CME

orm
18/12/18
Ranchi

Dr O P Sreevastav (Anesthetist),
Sis.Neeva ( Nursing Incharge), Mr.
Asish ( O.T Incharge)

Manvee Agency

29/12/18

2250

Rs.Value
3,733
1,142
850
820
1,007
807
662
1,992
916
160
395
 12,484

CME
Rs.Value
3,733
1,142
850
820
1,007
807
662
1,992
916
800
395

13,124

3,733
1,142
850
820
1,007
807
662
1,992
1,800
800
 395
900
783
400
560

16,651

3,733
879
1,215
1,025
2,921
1,009
799
2,324
1,833
2,412
592
772
1,175
783
400
1,100

22,972