I(~l ,';dI+'III,~=>:.,1. ~'~'fO - Food and Drug Administrationfdamyanmar.gov.mm/download/Regulation...
Transcript of I(~l ,';dI+'III,~=>:.,1. ~'~'fO - Food and Drug Administrationfdamyanmar.gov.mm/download/Regulation...
1_-
) ~~sect~~C~~l
CTlJ ~o~5-gt
r f 3Oraquoa3Oraquotcrl (gt JOo~)
CY(Jwgt~O~B50l)2 ~U)~~o1t9g~o ~6roG(I)~ ~O1 tP
20G3~a ~Ol amp(l~ (~)t9 3d4Jll)O ~o1 eOG3ampa~J ~a~ (s) ~3d1
~tcentCXYgt~ 08~cent~9tP~ CY(J9~~ g]~a~a CX~[9~ dc6ri2 (
011 g)i~~+06~ G3yen)oSol(1)lt7Ygtlamptrgt)~ Gltt3ol~~S ~a~ noSGcpoSGO
lQ~-
(00) ~~c88cop1yen2YgtCY1j-l~0tE9sgt~ Jgt-G-JOOJ loS~o1
~sGOOro~~~ JJOOJ Cn~ ~5 01 ltoo(o) (j) (raquo t (~) d 01
goS~~S~lt(I)~ GroolQP~ro~GOOS1 J8-7-JoO J loS~ 01
~S+ltsect5lPQY)3doS ~JOOJ ~ ~~~ 01 ltoo (0) (J) 9 (~)~ol
Q(X)~GcoO1Qnd3 ro~~ ~nc11II iJ-- t e L C
I(~l -dI+III~=gt1 ~~fO ltqJoSPti p-G-JOOJ
loS~o1 ~a~IS~~~~05yJOOJ ~ ~~amp gt1 800) (lt) o1~03o ~6roG(l)G)Y) ~o1tP~ ~l)211
J
cp~c8~9JL8 ~xgto1QP cq c3noS01 Goo~QcP~ Goo~cent QJO06centgtYgt
~poundtI8~~u~-(ro) ~J33doo8amp8 u8~Ga (ooo~QI) I
l bull J bull tj -l ~ ij- shy
( S ) sect~uS~ oS(ooo~QJ1
( 0 ) ooooS JOo ro amp8 3dOOoS~ (ooo~Qnl bull J bull ~l t lJshy
(00) ~+~ogggtioo 3d0(8~sectlXgtc2 3d~(ooo~Q~II
~n ~5 J OJ8 005sectanuel (OOOaxSooS~~OJ8 C)oS05~~a~Xgt~ ~~llY)
~o1eoG3~3d~ cxoo1 G6pS~g~3dOJ05 toS~oo8~ a808l~ sectSlQ~3dsect8
3J~c8f9JL8cooo1gpcf xY)Qf ~fsJL8~ooo1 GJcq Goo243~aY)cent
ooSor~QJJ3i1j C)oS~ ~~8~3t)06oS ~~ 89sectl~oS l~l~ xgtoS~8P CXO~3f8~
tooSoo~ ~~ 3daY)3d~~ (OOOo1~sect8oa8ro1 ~Gd3~ ~oSCXYgtlQ~1I
J 3gt~5 J 08 cltgt5=~ =IJI3gt0 3gtsecto=Ill~~Ocent ro05a3 ~Qlc8u)y 3d8lY) cxoo1~0G3ciS3d~ GOOo1sSIGS3dcnoS QchOoo8ampS c8808-t 11 L I c l[ G J c -l 110middot -0middot J L lmiddot L
l~~ sectSlQ~3dsect8 ~~~4ctI5tOOOo1 QJJ~ GOO(6~~ ouSO(~QJJ3i1j C)oS~
cocpS~893d0605 ~sectgt 39sectlsJoSl~l uoS~86p ~luS 3daY)3d~oS~ cxoo1
~sect806SroGl coagt5Qd3~ G~oSCXYgtlG~lI
~II ~CIl~49JLo tOOOo1~r~ xY)Q~4~JL5 CPm01QcP~ C)oS~ G~~l~ ~sectgt ~~sectlaUoS l~Gl3dCoS 3d~5 ~ ~ cy o3dl ~oSCXYgt~O~ G3i1joSoo5sect01
3dcoaYgtoS~CXYgt QJJ~ ltloJoo8sectlQ~-
(en) ~~Q~ GCX)o1 t9 (l)SC]egt)~ 3d~oS3dC)05fP-
( 0 ) GOOo13dQ~ [~neric andBrandname ( ~~8 )] I
(J ) GOOo1~nWJ ~ (GOOGOYgt9 1GOOsectgt I GOOjt1 (ooo~1 aGOOI
- ~llGOO I c8~GOO (l)gt)~Qp )I
GOOo1~ 3dGc)~~I O~C8)3d13dOJ05~ 01 oSjf t+2CXYgt1
cxoo1ooo)C)8lY~ OOQ~I 005~ampS i8C3dQ~1L bull L IX LO ~J L c
3)~lY)(OOOo1 eOG33dl aro)G9Xgt~ sect~oo~8c (OOOo1toS~oo8
3dQoSlIJ
j
bullbull
- -~
~ ~~81 ~
[B
81)
=
pound
amp
I)
8 01
) Q
~
o ~
Q)
8
o Q
)
8
g
c
o B
8
--
--
--
0
e
o
()1)
e
ca5C
e
cS
~
~8
~ 8
()
~ s
8 ID
g
r 2
G)
SJ3
i
8 1=$
S
~ ~
80~
sect ~
I$)
C
-amp0
0
1
co
8
~
8 -+
Q
) bullbull
8
~o
--B 8~
8 -amp
gtIl
uS
-a e
O
IV ~
-ampgt1)
0
e
o
8
~~
8 C8
13
g 8
01
) 8
sect-amp
0
8 c
C81
8
8
001)
8
e
S ~
9 ~
0
~
middot~r
U~middot~
=
n
0
Q
) ~
~8
0 sect
5 o
Q)
fit
e ~ s
~~
8
G)
c
-a
bullbull ()
cent
~
~
co
8sect
)
middot01
) a
D
~I)
S ~
G)
B
g g
~I) j
fl t
m~
8 8
~o
8 ~
bullbull
sect
sect 0
bullbull~
0 ~
o
cent
8 -
01
) G
) III
C sect
eo
vo
()
Q
bullbull
-amp0
0
sectl
3
I) lt
-e
0
8
gt
~ ij
00
~
It
CG1
C
~I)
tV
Q)
~
Ultgt
Q
cS
middot01
) 8
~
esect
8 ~
CsectJ
8 8
0
1)
8
middot01
)
) S
r
)0 ~
C
ocent
0
8
fB
I)
8 cS
J2
bullbull
-amp0
Q)~ j
~e
o ~
Q)
--B
bullbull
I)
8 ~
C
co
I)s
~
SL ~
0
G)
()
0 ~8
8~ ~
~
emiddot
8 8
S
Bm
eO
-601
)
J
B
QJ
(1
)
CGJ ~
-i3
()
t)
81)
sect Jcent
G
) (
)0
bullbull
I)
-0
cent 0
~8
8
01)
_
80
S
)
gt
II
)(
1) S ~
ailcent
~
ij
bullbull1)
pound
a
)
0
middot
gt
1
)8
0
fl ~
8 s
oss
B
~
)
o~I
)s
~ a
~
()1
) tS
-amp0
00
e ~mso
~
~ ~
do
~ 8
80 -
jraquoo
~
81)
fBI)
81
) -amp0
1)
8
80
p(3
fBl)
(
) ~
-
S 8
8
-t
0(11
)~
-amp0
e
8
bullbull
0 8
II)
G
)
2
8
0
bullbull
~
el) ~
08
~ 5 ~ ~
-to
0 ru
-amp
0
bullbull
[B
8
- ~
S0
S
0
~
OCJ
bullbull ~
fB
8 8
sect
-0gt1)
fl
8 ~
centI)
fil
1)
el) g
8
I bullbull l~middot
tl
G)
bullbull
0
-amp01)
S
~
=
8 ~
~
nl) c
gJ ~
-g C
~
C~
bullbull
~ II
)
~ ~o
i n
cgJ
~ ~
8 bullbull
~-egtI)p
8
(8)
~
G)
~
8
c8
~
~ ~
g 81
) ()1
) ~
$ i
B
8
)
bullbull
fl
cent ~ ~ ~
~l
1 ru
~
()
bullbull
bullbull
ocent
01
) o
cent
e 9
0
~ 03
i
~
g
tS lO
ocent
C
Icent ~
r)
8
8
bullbull i7
i ()
~
)
o CI
) ~
r
cent88
-amp
0
--
C
Q))
c8
0-
Gtl
bull
ocent
1)8~Q)
S fl
o 8
8
~ (
)I)
0
1)
)J
)
()
~
fl
gt Icent
i
Cn
8 tS ~
81
) G
) g
8
cent
gt -(
) cent
0 G
)8
()
0
2
80
tS
8
vmiddot
fBI)
8 ~
0
bullbull
8
)O
(1
)
gbullbull
0
8
bullbull
J~
-
amp3
gt
8I
CJ
middotmiddot
(81
)~()
II)
Q
~g
()
8
s ~
~
r)
)
J
-
amp3
J3
-fgt
oo
~
0 8
~ -0gt
1) ~
()
lSJ
ru
ampe
E
s c
oQ)
1
8
rB
~I) sect
I)
gt1
tJ 01
) ID
01
)~
g
ffiJ
8
c
sect reg~
cent
8
l
()
CI)
8 8
ti
8
0
lOJ
~
f+
sect G
) 8
U
c8
8 C
I)
t1)
80
8 -
sect
2 ~
~ 3~
~I)~
[B1
)8
I)
08
~o
O
-t
8
~ o
cOQ
8 ~
0 8~
()middotmiddot
8
81
) ij
8
(1)
-ampgtI
l bullbull
~
S
ocent
8
() ~Q
-ar
s~~
~Q
8
J
8
eo
~
c
80
~gO
~
en -amp
gt
p(
3 I
O
8
0 t
gIl
tjl)
8
(1)
SS8
middot0
~ lt
5 RI
)
u bullbull
~
0 (
)
gl)
~
IS
_
-+I
)
)
0
~ ~
lgt
middot01
)o
e I)
bullbull
~-0gt
bullbull ~
80
$
g
=
bull 9 (00) 03~9JLo~o1G~ec3~rosect~ cPe~P068 cooeytxgt9 tfJ
~t~cJ d3~S~83dgt ~~s~~~~sect8~sectL911
~ a49J15 c=olP ~1h~I9t~laquop~~~~~~ ~2=~~o1 Sd68 ltOOlY)8a05lt~-middot
(()) lt8~~lo ~o1~~~ 3d~oClYgtsectljt~ ~o~~~~ roooaoSl~3d0605 I ) 3)ltgti afi8 ~~00~ltXY)lt~1I
(00) c8~aJlO GOOo1t~~ Sd~5 7068Xgt~3doe ~J~ro
~tlYcJ ~~ltIY)Sd~oT oo800 ~~~05sectgtYgt~~lt~11 o ~as~~ 3dGP8~sectCIY)ro05ampqe ~8~8 ~ltXY)l~~1I
(e) 3d~~~ro8~ooS~l9~~(xy)~~~11
(4D) l)05tcampYJl)~ q~~J01 aaoo OuS~l)~ CaYgt~Jcent GPeaJ
xgt~csect~~J~~t~11
(00) ~~~2~~l)05P~~ ~~~~ Sda1~~~~~sect8~ ~~II
eft (O) 3d~8 J 01 (OOO~8~~sect Sd~03~ampJLo~o1~p+ OYgtQ+03~~l8~o1
~p coP8aJ9~ gsectLaJ05 l~~Xgt~ ~o1~~ ooSt~8~aS
~sect8 roQ)~ ~q~i(9)~ ~~ - ~ooS 008 tH8SdaYgt3dcoxxgt05 amp 8 cooo1 ~r~JL~~bulltJt~ J bull L J bull e-~ ~J~J~r-JJOCfVJ~
-if ~ (Q) 3)q8 J 01 Goo~ eQp=j3)0 lY)Q~~tcmoGooo1Qp GreQJlt
g~lltJ05 lsect~~~ Qd)ol 3)~l~~ ooS~ctlS~a05 ooSO(~ctI
sectS ()cent)23d~Sampro ~~ q0 ($) tq ~05PsectloS3XY)~cent (0001 ~isecto06S00GlGCn5Qd5~ OOcent)2()CO~ (7) loS~~ coo~f9
e~3)0)~~oooSt9 Groo1~sect~ooo1 ~d5~ SampllGOlQ~1I
lOll (00) ~~~coP0~ (Consultant) ~CO~9 3)OOoSCOP0~ Qpgtgt~
~~~ii)JL8GaoolQJgt ~ lY)Q~~iCi)Jl8GaoolQP~ 0050(
CYtgtgtl ~ygtrY)GCOt6ro GOsectSI GcoCYtDGosectS sectlt~~~11
(Ci)) ~+Q)~e~~11 at~l~Illttllo ~QOoS a+sectgt1~IFlt)Jlampn ~3)o
C1Y)O~Go~gtgt~ ~~c8~~toGcool QJO~ ooSO(CYtgtgtl~ Gcoapgtgtgcent
()05y~coP0+reg) GltiOa+ro3)lOOT 000OO9GcxrJoSamp~05 roSgtgt~u
( 0 ) GOOCYtgtgt8cent C)05~oSl oofgtO+~2 OOQ+c8~toGCOolQJJo ooSO(
CYtgtgtl+ ~ygt3dJ GCOa+roOOsectS1 CYtgtgtsectSsectlSgtgt~1I
gtgt11 (00 ) ~sectIl~tcent CYtgtgtGl~~~ I ~+sectYGl~II~tO ~QOoS tpoundtamp~r~lt~lo m ~~O C1Y)0+Go~gtgt2 ~~03~Ci)JloGCOolQP~ o~ CYtgtgtl~
~~~fX~~ GQ)~ro3xoT_oo~8gtgt~
(Q ) ~GaOCYtaofgtOgtgt~ lX)Q~~ampoaoolQJd ~~
~SlS3d) GOOas+rorosectS1 d5~+~CYtDsectS sectlSO~1I
OJII 34188 00 amp8 00 03~a Goomgtgtgtgt~ COGY)oagtgt~ C)JQ05O)~ 8QID05 l J deg Lo -L l ex -l- f c It J lO L
cSlW+GOOCYtl)~ ~oSO)~ sectlO CltY)~lQ~1I
~ 3d~8 00 ~ 00 o3()l GOOJ~roGogtgt~ OOPOD~ coas+=roOO~06S ~
ro~G(TY)SlGOOCYtgtgtl)~ coP0~gtgt~ 3)8 OJ ~l orygt~05O)~ ~oQor05 d3b~
cooCYtgtgtj ~050)~ sectloCXY)~P06S ()2GOYgteshy
(m) ~013H~J05QP 01 ~oolQ2-
(raquo ilygt3dQ~1 mp1 QI3)l)oSl 65T sectSolm dS~~ladQ~
(J) oo~ gt3QID05 d3aQY)~8SaS~ gScoo S~SGam~C~1 IL - Lo L -10 f L Jl l -l tj J
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
J
cp~c8~9JL8 ~xgto1QP cq c3noS01 Goo~QcP~ Goo~cent QJO06centgtYgt
~poundtI8~~u~-(ro) ~J33doo8amp8 u8~Ga (ooo~QI) I
l bull J bull tj -l ~ ij- shy
( S ) sect~uS~ oS(ooo~QJ1
( 0 ) ooooS JOo ro amp8 3dOOoS~ (ooo~Qnl bull J bull ~l t lJshy
(00) ~+~ogggtioo 3d0(8~sectlXgtc2 3d~(ooo~Q~II
~n ~5 J OJ8 005sectanuel (OOOaxSooS~~OJ8 C)oS05~~a~Xgt~ ~~llY)
~o1eoG3~3d~ cxoo1 G6pS~g~3dOJ05 toS~oo8~ a808l~ sectSlQ~3dsect8
3J~c8f9JL8cooo1gpcf xY)Qf ~fsJL8~ooo1 GJcq Goo243~aY)cent
ooSor~QJJ3i1j C)oS~ ~~8~3t)06oS ~~ 89sectl~oS l~l~ xgtoS~8P CXO~3f8~
tooSoo~ ~~ 3daY)3d~~ (OOOo1~sect8oa8ro1 ~Gd3~ ~oSCXYgtlQ~1I
J 3gt~5 J 08 cltgt5=~ =IJI3gt0 3gtsecto=Ill~~Ocent ro05a3 ~Qlc8u)y 3d8lY) cxoo1~0G3ciS3d~ GOOo1sSIGS3dcnoS QchOoo8ampS c8808-t 11 L I c l[ G J c -l 110middot -0middot J L lmiddot L
l~~ sectSlQ~3dsect8 ~~~4ctI5tOOOo1 QJJ~ GOO(6~~ ouSO(~QJJ3i1j C)oS~
cocpS~893d0605 ~sectgt 39sectlsJoSl~l uoS~86p ~luS 3daY)3d~oS~ cxoo1
~sect806SroGl coagt5Qd3~ G~oSCXYgtlG~lI
~II ~CIl~49JLo tOOOo1~r~ xY)Q~4~JL5 CPm01QcP~ C)oS~ G~~l~ ~sectgt ~~sectlaUoS l~Gl3dCoS 3d~5 ~ ~ cy o3dl ~oSCXYgt~O~ G3i1joSoo5sect01
3dcoaYgtoS~CXYgt QJJ~ ltloJoo8sectlQ~-
(en) ~~Q~ GCX)o1 t9 (l)SC]egt)~ 3d~oS3dC)05fP-
( 0 ) GOOo13dQ~ [~neric andBrandname ( ~~8 )] I
(J ) GOOo1~nWJ ~ (GOOGOYgt9 1GOOsectgt I GOOjt1 (ooo~1 aGOOI
- ~llGOO I c8~GOO (l)gt)~Qp )I
GOOo1~ 3dGc)~~I O~C8)3d13dOJ05~ 01 oSjf t+2CXYgt1
cxoo1ooo)C)8lY~ OOQ~I 005~ampS i8C3dQ~1L bull L IX LO ~J L c
3)~lY)(OOOo1 eOG33dl aro)G9Xgt~ sect~oo~8c (OOOo1toS~oo8
3dQoSlIJ
j
bullbull
- -~
~ ~~81 ~
[B
81)
=
pound
amp
I)
8 01
) Q
~
o ~
Q)
8
o Q
)
8
g
c
o B
8
--
--
--
0
e
o
()1)
e
ca5C
e
cS
~
~8
~ 8
()
~ s
8 ID
g
r 2
G)
SJ3
i
8 1=$
S
~ ~
80~
sect ~
I$)
C
-amp0
0
1
co
8
~
8 -+
Q
) bullbull
8
~o
--B 8~
8 -amp
gtIl
uS
-a e
O
IV ~
-ampgt1)
0
e
o
8
~~
8 C8
13
g 8
01
) 8
sect-amp
0
8 c
C81
8
8
001)
8
e
S ~
9 ~
0
~
middot~r
U~middot~
=
n
0
Q
) ~
~8
0 sect
5 o
Q)
fit
e ~ s
~~
8
G)
c
-a
bullbull ()
cent
~
~
co
8sect
)
middot01
) a
D
~I)
S ~
G)
B
g g
~I) j
fl t
m~
8 8
~o
8 ~
bullbull
sect
sect 0
bullbull~
0 ~
o
cent
8 -
01
) G
) III
C sect
eo
vo
()
Q
bullbull
-amp0
0
sectl
3
I) lt
-e
0
8
gt
~ ij
00
~
It
CG1
C
~I)
tV
Q)
~
Ultgt
Q
cS
middot01
) 8
~
esect
8 ~
CsectJ
8 8
0
1)
8
middot01
)
) S
r
)0 ~
C
ocent
0
8
fB
I)
8 cS
J2
bullbull
-amp0
Q)~ j
~e
o ~
Q)
--B
bullbull
I)
8 ~
C
co
I)s
~
SL ~
0
G)
()
0 ~8
8~ ~
~
emiddot
8 8
S
Bm
eO
-601
)
J
B
QJ
(1
)
CGJ ~
-i3
()
t)
81)
sect Jcent
G
) (
)0
bullbull
I)
-0
cent 0
~8
8
01)
_
80
S
)
gt
II
)(
1) S ~
ailcent
~
ij
bullbull1)
pound
a
)
0
middot
gt
1
)8
0
fl ~
8 s
oss
B
~
)
o~I
)s
~ a
~
()1
) tS
-amp0
00
e ~mso
~
~ ~
do
~ 8
80 -
jraquoo
~
81)
fBI)
81
) -amp0
1)
8
80
p(3
fBl)
(
) ~
-
S 8
8
-t
0(11
)~
-amp0
e
8
bullbull
0 8
II)
G
)
2
8
0
bullbull
~
el) ~
08
~ 5 ~ ~
-to
0 ru
-amp
0
bullbull
[B
8
- ~
S0
S
0
~
OCJ
bullbull ~
fB
8 8
sect
-0gt1)
fl
8 ~
centI)
fil
1)
el) g
8
I bullbull l~middot
tl
G)
bullbull
0
-amp01)
S
~
=
8 ~
~
nl) c
gJ ~
-g C
~
C~
bullbull
~ II
)
~ ~o
i n
cgJ
~ ~
8 bullbull
~-egtI)p
8
(8)
~
G)
~
8
c8
~
~ ~
g 81
) ()1
) ~
$ i
B
8
)
bullbull
fl
cent ~ ~ ~
~l
1 ru
~
()
bullbull
bullbull
ocent
01
) o
cent
e 9
0
~ 03
i
~
g
tS lO
ocent
C
Icent ~
r)
8
8
bullbull i7
i ()
~
)
o CI
) ~
r
cent88
-amp
0
--
C
Q))
c8
0-
Gtl
bull
ocent
1)8~Q)
S fl
o 8
8
~ (
)I)
0
1)
)J
)
()
~
fl
gt Icent
i
Cn
8 tS ~
81
) G
) g
8
cent
gt -(
) cent
0 G
)8
()
0
2
80
tS
8
vmiddot
fBI)
8 ~
0
bullbull
8
)O
(1
)
gbullbull
0
8
bullbull
J~
-
amp3
gt
8I
CJ
middotmiddot
(81
)~()
II)
Q
~g
()
8
s ~
~
r)
)
J
-
amp3
J3
-fgt
oo
~
0 8
~ -0gt
1) ~
()
lSJ
ru
ampe
E
s c
oQ)
1
8
rB
~I) sect
I)
gt1
tJ 01
) ID
01
)~
g
ffiJ
8
c
sect reg~
cent
8
l
()
CI)
8 8
ti
8
0
lOJ
~
f+
sect G
) 8
U
c8
8 C
I)
t1)
80
8 -
sect
2 ~
~ 3~
~I)~
[B1
)8
I)
08
~o
O
-t
8
~ o
cOQ
8 ~
0 8~
()middotmiddot
8
81
) ij
8
(1)
-ampgtI
l bullbull
~
S
ocent
8
() ~Q
-ar
s~~
~Q
8
J
8
eo
~
c
80
~gO
~
en -amp
gt
p(
3 I
O
8
0 t
gIl
tjl)
8
(1)
SS8
middot0
~ lt
5 RI
)
u bullbull
~
0 (
)
gl)
~
IS
_
-+I
)
)
0
~ ~
lgt
middot01
)o
e I)
bullbull
~-0gt
bullbull ~
80
$
g
=
bull 9 (00) 03~9JLo~o1G~ec3~rosect~ cPe~P068 cooeytxgt9 tfJ
~t~cJ d3~S~83dgt ~~s~~~~sect8~sectL911
~ a49J15 c=olP ~1h~I9t~laquop~~~~~~ ~2=~~o1 Sd68 ltOOlY)8a05lt~-middot
(()) lt8~~lo ~o1~~~ 3d~oClYgtsectljt~ ~o~~~~ roooaoSl~3d0605 I ) 3)ltgti afi8 ~~00~ltXY)lt~1I
(00) c8~aJlO GOOo1t~~ Sd~5 7068Xgt~3doe ~J~ro
~tlYcJ ~~ltIY)Sd~oT oo800 ~~~05sectgtYgt~~lt~11 o ~as~~ 3dGP8~sectCIY)ro05ampqe ~8~8 ~ltXY)l~~1I
(e) 3d~~~ro8~ooS~l9~~(xy)~~~11
(4D) l)05tcampYJl)~ q~~J01 aaoo OuS~l)~ CaYgt~Jcent GPeaJ
xgt~csect~~J~~t~11
(00) ~~~2~~l)05P~~ ~~~~ Sda1~~~~~sect8~ ~~II
eft (O) 3d~8 J 01 (OOO~8~~sect Sd~03~ampJLo~o1~p+ OYgtQ+03~~l8~o1
~p coP8aJ9~ gsectLaJ05 l~~Xgt~ ~o1~~ ooSt~8~aS
~sect8 roQ)~ ~q~i(9)~ ~~ - ~ooS 008 tH8SdaYgt3dcoxxgt05 amp 8 cooo1 ~r~JL~~bulltJt~ J bull L J bull e-~ ~J~J~r-JJOCfVJ~
-if ~ (Q) 3)q8 J 01 Goo~ eQp=j3)0 lY)Q~~tcmoGooo1Qp GreQJlt
g~lltJ05 lsect~~~ Qd)ol 3)~l~~ ooS~ctlS~a05 ooSO(~ctI
sectS ()cent)23d~Sampro ~~ q0 ($) tq ~05PsectloS3XY)~cent (0001 ~isecto06S00GlGCn5Qd5~ OOcent)2()CO~ (7) loS~~ coo~f9
e~3)0)~~oooSt9 Groo1~sect~ooo1 ~d5~ SampllGOlQ~1I
lOll (00) ~~~coP0~ (Consultant) ~CO~9 3)OOoSCOP0~ Qpgtgt~
~~~ii)JL8GaoolQJgt ~ lY)Q~~iCi)Jl8GaoolQP~ 0050(
CYtgtgtl ~ygtrY)GCOt6ro GOsectSI GcoCYtDGosectS sectlt~~~11
(Ci)) ~+Q)~e~~11 at~l~Illttllo ~QOoS a+sectgt1~IFlt)Jlampn ~3)o
C1Y)O~Go~gtgt~ ~~c8~~toGcool QJO~ ooSO(CYtgtgtl~ Gcoapgtgtgcent
()05y~coP0+reg) GltiOa+ro3)lOOT 000OO9GcxrJoSamp~05 roSgtgt~u
( 0 ) GOOCYtgtgt8cent C)05~oSl oofgtO+~2 OOQ+c8~toGCOolQJJo ooSO(
CYtgtgtl+ ~ygt3dJ GCOa+roOOsectS1 CYtgtgtsectSsectlSgtgt~1I
gtgt11 (00 ) ~sectIl~tcent CYtgtgtGl~~~ I ~+sectYGl~II~tO ~QOoS tpoundtamp~r~lt~lo m ~~O C1Y)0+Go~gtgt2 ~~03~Ci)JloGCOolQP~ o~ CYtgtgtl~
~~~fX~~ GQ)~ro3xoT_oo~8gtgt~
(Q ) ~GaOCYtaofgtOgtgt~ lX)Q~~ampoaoolQJd ~~
~SlS3d) GOOas+rorosectS1 d5~+~CYtDsectS sectlSO~1I
OJII 34188 00 amp8 00 03~a Goomgtgtgtgt~ COGY)oagtgt~ C)JQ05O)~ 8QID05 l J deg Lo -L l ex -l- f c It J lO L
cSlW+GOOCYtl)~ ~oSO)~ sectlO CltY)~lQ~1I
~ 3d~8 00 ~ 00 o3()l GOOJ~roGogtgt~ OOPOD~ coas+=roOO~06S ~
ro~G(TY)SlGOOCYtgtgtl)~ coP0~gtgt~ 3)8 OJ ~l orygt~05O)~ ~oQor05 d3b~
cooCYtgtgtj ~050)~ sectloCXY)~P06S ()2GOYgteshy
(m) ~013H~J05QP 01 ~oolQ2-
(raquo ilygt3dQ~1 mp1 QI3)l)oSl 65T sectSolm dS~~ladQ~
(J) oo~ gt3QID05 d3aQY)~8SaS~ gScoo S~SGam~C~1 IL - Lo L -10 f L Jl l -l tj J
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
bullbull
- -~
~ ~~81 ~
[B
81)
=
pound
amp
I)
8 01
) Q
~
o ~
Q)
8
o Q
)
8
g
c
o B
8
--
--
--
0
e
o
()1)
e
ca5C
e
cS
~
~8
~ 8
()
~ s
8 ID
g
r 2
G)
SJ3
i
8 1=$
S
~ ~
80~
sect ~
I$)
C
-amp0
0
1
co
8
~
8 -+
Q
) bullbull
8
~o
--B 8~
8 -amp
gtIl
uS
-a e
O
IV ~
-ampgt1)
0
e
o
8
~~
8 C8
13
g 8
01
) 8
sect-amp
0
8 c
C81
8
8
001)
8
e
S ~
9 ~
0
~
middot~r
U~middot~
=
n
0
Q
) ~
~8
0 sect
5 o
Q)
fit
e ~ s
~~
8
G)
c
-a
bullbull ()
cent
~
~
co
8sect
)
middot01
) a
D
~I)
S ~
G)
B
g g
~I) j
fl t
m~
8 8
~o
8 ~
bullbull
sect
sect 0
bullbull~
0 ~
o
cent
8 -
01
) G
) III
C sect
eo
vo
()
Q
bullbull
-amp0
0
sectl
3
I) lt
-e
0
8
gt
~ ij
00
~
It
CG1
C
~I)
tV
Q)
~
Ultgt
Q
cS
middot01
) 8
~
esect
8 ~
CsectJ
8 8
0
1)
8
middot01
)
) S
r
)0 ~
C
ocent
0
8
fB
I)
8 cS
J2
bullbull
-amp0
Q)~ j
~e
o ~
Q)
--B
bullbull
I)
8 ~
C
co
I)s
~
SL ~
0
G)
()
0 ~8
8~ ~
~
emiddot
8 8
S
Bm
eO
-601
)
J
B
QJ
(1
)
CGJ ~
-i3
()
t)
81)
sect Jcent
G
) (
)0
bullbull
I)
-0
cent 0
~8
8
01)
_
80
S
)
gt
II
)(
1) S ~
ailcent
~
ij
bullbull1)
pound
a
)
0
middot
gt
1
)8
0
fl ~
8 s
oss
B
~
)
o~I
)s
~ a
~
()1
) tS
-amp0
00
e ~mso
~
~ ~
do
~ 8
80 -
jraquoo
~
81)
fBI)
81
) -amp0
1)
8
80
p(3
fBl)
(
) ~
-
S 8
8
-t
0(11
)~
-amp0
e
8
bullbull
0 8
II)
G
)
2
8
0
bullbull
~
el) ~
08
~ 5 ~ ~
-to
0 ru
-amp
0
bullbull
[B
8
- ~
S0
S
0
~
OCJ
bullbull ~
fB
8 8
sect
-0gt1)
fl
8 ~
centI)
fil
1)
el) g
8
I bullbull l~middot
tl
G)
bullbull
0
-amp01)
S
~
=
8 ~
~
nl) c
gJ ~
-g C
~
C~
bullbull
~ II
)
~ ~o
i n
cgJ
~ ~
8 bullbull
~-egtI)p
8
(8)
~
G)
~
8
c8
~
~ ~
g 81
) ()1
) ~
$ i
B
8
)
bullbull
fl
cent ~ ~ ~
~l
1 ru
~
()
bullbull
bullbull
ocent
01
) o
cent
e 9
0
~ 03
i
~
g
tS lO
ocent
C
Icent ~
r)
8
8
bullbull i7
i ()
~
)
o CI
) ~
r
cent88
-amp
0
--
C
Q))
c8
0-
Gtl
bull
ocent
1)8~Q)
S fl
o 8
8
~ (
)I)
0
1)
)J
)
()
~
fl
gt Icent
i
Cn
8 tS ~
81
) G
) g
8
cent
gt -(
) cent
0 G
)8
()
0
2
80
tS
8
vmiddot
fBI)
8 ~
0
bullbull
8
)O
(1
)
gbullbull
0
8
bullbull
J~
-
amp3
gt
8I
CJ
middotmiddot
(81
)~()
II)
Q
~g
()
8
s ~
~
r)
)
J
-
amp3
J3
-fgt
oo
~
0 8
~ -0gt
1) ~
()
lSJ
ru
ampe
E
s c
oQ)
1
8
rB
~I) sect
I)
gt1
tJ 01
) ID
01
)~
g
ffiJ
8
c
sect reg~
cent
8
l
()
CI)
8 8
ti
8
0
lOJ
~
f+
sect G
) 8
U
c8
8 C
I)
t1)
80
8 -
sect
2 ~
~ 3~
~I)~
[B1
)8
I)
08
~o
O
-t
8
~ o
cOQ
8 ~
0 8~
()middotmiddot
8
81
) ij
8
(1)
-ampgtI
l bullbull
~
S
ocent
8
() ~Q
-ar
s~~
~Q
8
J
8
eo
~
c
80
~gO
~
en -amp
gt
p(
3 I
O
8
0 t
gIl
tjl)
8
(1)
SS8
middot0
~ lt
5 RI
)
u bullbull
~
0 (
)
gl)
~
IS
_
-+I
)
)
0
~ ~
lgt
middot01
)o
e I)
bullbull
~-0gt
bullbull ~
80
$
g
=
bull 9 (00) 03~9JLo~o1G~ec3~rosect~ cPe~P068 cooeytxgt9 tfJ
~t~cJ d3~S~83dgt ~~s~~~~sect8~sectL911
~ a49J15 c=olP ~1h~I9t~laquop~~~~~~ ~2=~~o1 Sd68 ltOOlY)8a05lt~-middot
(()) lt8~~lo ~o1~~~ 3d~oClYgtsectljt~ ~o~~~~ roooaoSl~3d0605 I ) 3)ltgti afi8 ~~00~ltXY)lt~1I
(00) c8~aJlO GOOo1t~~ Sd~5 7068Xgt~3doe ~J~ro
~tlYcJ ~~ltIY)Sd~oT oo800 ~~~05sectgtYgt~~lt~11 o ~as~~ 3dGP8~sectCIY)ro05ampqe ~8~8 ~ltXY)l~~1I
(e) 3d~~~ro8~ooS~l9~~(xy)~~~11
(4D) l)05tcampYJl)~ q~~J01 aaoo OuS~l)~ CaYgt~Jcent GPeaJ
xgt~csect~~J~~t~11
(00) ~~~2~~l)05P~~ ~~~~ Sda1~~~~~sect8~ ~~II
eft (O) 3d~8 J 01 (OOO~8~~sect Sd~03~ampJLo~o1~p+ OYgtQ+03~~l8~o1
~p coP8aJ9~ gsectLaJ05 l~~Xgt~ ~o1~~ ooSt~8~aS
~sect8 roQ)~ ~q~i(9)~ ~~ - ~ooS 008 tH8SdaYgt3dcoxxgt05 amp 8 cooo1 ~r~JL~~bulltJt~ J bull L J bull e-~ ~J~J~r-JJOCfVJ~
-if ~ (Q) 3)q8 J 01 Goo~ eQp=j3)0 lY)Q~~tcmoGooo1Qp GreQJlt
g~lltJ05 lsect~~~ Qd)ol 3)~l~~ ooS~ctlS~a05 ooSO(~ctI
sectS ()cent)23d~Sampro ~~ q0 ($) tq ~05PsectloS3XY)~cent (0001 ~isecto06S00GlGCn5Qd5~ OOcent)2()CO~ (7) loS~~ coo~f9
e~3)0)~~oooSt9 Groo1~sect~ooo1 ~d5~ SampllGOlQ~1I
lOll (00) ~~~coP0~ (Consultant) ~CO~9 3)OOoSCOP0~ Qpgtgt~
~~~ii)JL8GaoolQJgt ~ lY)Q~~iCi)Jl8GaoolQP~ 0050(
CYtgtgtl ~ygtrY)GCOt6ro GOsectSI GcoCYtDGosectS sectlt~~~11
(Ci)) ~+Q)~e~~11 at~l~Illttllo ~QOoS a+sectgt1~IFlt)Jlampn ~3)o
C1Y)O~Go~gtgt~ ~~c8~~toGcool QJO~ ooSO(CYtgtgtl~ Gcoapgtgtgcent
()05y~coP0+reg) GltiOa+ro3)lOOT 000OO9GcxrJoSamp~05 roSgtgt~u
( 0 ) GOOCYtgtgt8cent C)05~oSl oofgtO+~2 OOQ+c8~toGCOolQJJo ooSO(
CYtgtgtl+ ~ygt3dJ GCOa+roOOsectS1 CYtgtgtsectSsectlSgtgt~1I
gtgt11 (00 ) ~sectIl~tcent CYtgtgtGl~~~ I ~+sectYGl~II~tO ~QOoS tpoundtamp~r~lt~lo m ~~O C1Y)0+Go~gtgt2 ~~03~Ci)JloGCOolQP~ o~ CYtgtgtl~
~~~fX~~ GQ)~ro3xoT_oo~8gtgt~
(Q ) ~GaOCYtaofgtOgtgt~ lX)Q~~ampoaoolQJd ~~
~SlS3d) GOOas+rorosectS1 d5~+~CYtDsectS sectlSO~1I
OJII 34188 00 amp8 00 03~a Goomgtgtgtgt~ COGY)oagtgt~ C)JQ05O)~ 8QID05 l J deg Lo -L l ex -l- f c It J lO L
cSlW+GOOCYtl)~ ~oSO)~ sectlO CltY)~lQ~1I
~ 3d~8 00 ~ 00 o3()l GOOJ~roGogtgt~ OOPOD~ coas+=roOO~06S ~
ro~G(TY)SlGOOCYtgtgtl)~ coP0~gtgt~ 3)8 OJ ~l orygt~05O)~ ~oQor05 d3b~
cooCYtgtgtj ~050)~ sectloCXY)~P06S ()2GOYgteshy
(m) ~013H~J05QP 01 ~oolQ2-
(raquo ilygt3dQ~1 mp1 QI3)l)oSl 65T sectSolm dS~~ladQ~
(J) oo~ gt3QID05 d3aQY)~8SaS~ gScoo S~SGam~C~1 IL - Lo L -10 f L Jl l -l tj J
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
bull 9 (00) 03~9JLo~o1G~ec3~rosect~ cPe~P068 cooeytxgt9 tfJ
~t~cJ d3~S~83dgt ~~s~~~~sect8~sectL911
~ a49J15 c=olP ~1h~I9t~laquop~~~~~~ ~2=~~o1 Sd68 ltOOlY)8a05lt~-middot
(()) lt8~~lo ~o1~~~ 3d~oClYgtsectljt~ ~o~~~~ roooaoSl~3d0605 I ) 3)ltgti afi8 ~~00~ltXY)lt~1I
(00) c8~aJlO GOOo1t~~ Sd~5 7068Xgt~3doe ~J~ro
~tlYcJ ~~ltIY)Sd~oT oo800 ~~~05sectgtYgt~~lt~11 o ~as~~ 3dGP8~sectCIY)ro05ampqe ~8~8 ~ltXY)l~~1I
(e) 3d~~~ro8~ooS~l9~~(xy)~~~11
(4D) l)05tcampYJl)~ q~~J01 aaoo OuS~l)~ CaYgt~Jcent GPeaJ
xgt~csect~~J~~t~11
(00) ~~~2~~l)05P~~ ~~~~ Sda1~~~~~sect8~ ~~II
eft (O) 3d~8 J 01 (OOO~8~~sect Sd~03~ampJLo~o1~p+ OYgtQ+03~~l8~o1
~p coP8aJ9~ gsectLaJ05 l~~Xgt~ ~o1~~ ooSt~8~aS
~sect8 roQ)~ ~q~i(9)~ ~~ - ~ooS 008 tH8SdaYgt3dcoxxgt05 amp 8 cooo1 ~r~JL~~bulltJt~ J bull L J bull e-~ ~J~J~r-JJOCfVJ~
-if ~ (Q) 3)q8 J 01 Goo~ eQp=j3)0 lY)Q~~tcmoGooo1Qp GreQJlt
g~lltJ05 lsect~~~ Qd)ol 3)~l~~ ooS~ctlS~a05 ooSO(~ctI
sectS ()cent)23d~Sampro ~~ q0 ($) tq ~05PsectloS3XY)~cent (0001 ~isecto06S00GlGCn5Qd5~ OOcent)2()CO~ (7) loS~~ coo~f9
e~3)0)~~oooSt9 Groo1~sect~ooo1 ~d5~ SampllGOlQ~1I
lOll (00) ~~~coP0~ (Consultant) ~CO~9 3)OOoSCOP0~ Qpgtgt~
~~~ii)JL8GaoolQJgt ~ lY)Q~~iCi)Jl8GaoolQP~ 0050(
CYtgtgtl ~ygtrY)GCOt6ro GOsectSI GcoCYtDGosectS sectlt~~~11
(Ci)) ~+Q)~e~~11 at~l~Illttllo ~QOoS a+sectgt1~IFlt)Jlampn ~3)o
C1Y)O~Go~gtgt~ ~~c8~~toGcool QJO~ ooSO(CYtgtgtl~ Gcoapgtgtgcent
()05y~coP0+reg) GltiOa+ro3)lOOT 000OO9GcxrJoSamp~05 roSgtgt~u
( 0 ) GOOCYtgtgt8cent C)05~oSl oofgtO+~2 OOQ+c8~toGCOolQJJo ooSO(
CYtgtgtl+ ~ygt3dJ GCOa+roOOsectS1 CYtgtgtsectSsectlSgtgt~1I
gtgt11 (00 ) ~sectIl~tcent CYtgtgtGl~~~ I ~+sectYGl~II~tO ~QOoS tpoundtamp~r~lt~lo m ~~O C1Y)0+Go~gtgt2 ~~03~Ci)JloGCOolQP~ o~ CYtgtgtl~
~~~fX~~ GQ)~ro3xoT_oo~8gtgt~
(Q ) ~GaOCYtaofgtOgtgt~ lX)Q~~ampoaoolQJd ~~
~SlS3d) GOOas+rorosectS1 d5~+~CYtDsectS sectlSO~1I
OJII 34188 00 amp8 00 03~a Goomgtgtgtgt~ COGY)oagtgt~ C)JQ05O)~ 8QID05 l J deg Lo -L l ex -l- f c It J lO L
cSlW+GOOCYtl)~ ~oSO)~ sectlO CltY)~lQ~1I
~ 3d~8 00 ~ 00 o3()l GOOJ~roGogtgt~ OOPOD~ coas+=roOO~06S ~
ro~G(TY)SlGOOCYtgtgtl)~ coP0~gtgt~ 3)8 OJ ~l orygt~05O)~ ~oQor05 d3b~
cooCYtgtgtj ~050)~ sectloCXY)~P06S ()2GOYgteshy
(m) ~013H~J05QP 01 ~oolQ2-
(raquo ilygt3dQ~1 mp1 QI3)l)oSl 65T sectSolm dS~~ladQ~
(J) oo~ gt3QID05 d3aQY)~8SaS~ gScoo S~SGam~C~1 IL - Lo L -10 f L Jl l -l tj J
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
-if ~ (Q) 3)q8 J 01 Goo~ eQp=j3)0 lY)Q~~tcmoGooo1Qp GreQJlt
g~lltJ05 lsect~~~ Qd)ol 3)~l~~ ooS~ctlS~a05 ooSO(~ctI
sectS ()cent)23d~Sampro ~~ q0 ($) tq ~05PsectloS3XY)~cent (0001 ~isecto06S00GlGCn5Qd5~ OOcent)2()CO~ (7) loS~~ coo~f9
e~3)0)~~oooSt9 Groo1~sect~ooo1 ~d5~ SampllGOlQ~1I
lOll (00) ~~~coP0~ (Consultant) ~CO~9 3)OOoSCOP0~ Qpgtgt~
~~~ii)JL8GaoolQJgt ~ lY)Q~~iCi)Jl8GaoolQP~ 0050(
CYtgtgtl ~ygtrY)GCOt6ro GOsectSI GcoCYtDGosectS sectlt~~~11
(Ci)) ~+Q)~e~~11 at~l~Illttllo ~QOoS a+sectgt1~IFlt)Jlampn ~3)o
C1Y)O~Go~gtgt~ ~~c8~~toGcool QJO~ ooSO(CYtgtgtl~ Gcoapgtgtgcent
()05y~coP0+reg) GltiOa+ro3)lOOT 000OO9GcxrJoSamp~05 roSgtgt~u
( 0 ) GOOCYtgtgt8cent C)05~oSl oofgtO+~2 OOQ+c8~toGCOolQJJo ooSO(
CYtgtgtl+ ~ygt3dJ GCOa+roOOsectS1 CYtgtgtsectSsectlSgtgt~1I
gtgt11 (00 ) ~sectIl~tcent CYtgtgtGl~~~ I ~+sectYGl~II~tO ~QOoS tpoundtamp~r~lt~lo m ~~O C1Y)0+Go~gtgt2 ~~03~Ci)JloGCOolQP~ o~ CYtgtgtl~
~~~fX~~ GQ)~ro3xoT_oo~8gtgt~
(Q ) ~GaOCYtaofgtOgtgt~ lX)Q~~ampoaoolQJd ~~
~SlS3d) GOOas+rorosectS1 d5~+~CYtDsectS sectlSO~1I
OJII 34188 00 amp8 00 03~a Goomgtgtgtgt~ COGY)oagtgt~ C)JQ05O)~ 8QID05 l J deg Lo -L l ex -l- f c It J lO L
cSlW+GOOCYtl)~ ~oSO)~ sectlO CltY)~lQ~1I
~ 3d~8 00 ~ 00 o3()l GOOJ~roGogtgt~ OOPOD~ coas+=roOO~06S ~
ro~G(TY)SlGOOCYtgtgtl)~ coP0~gtgt~ 3)8 OJ ~l orygt~05O)~ ~oQor05 d3b~
cooCYtgtgtj ~050)~ sectloCXY)~P06S ()2GOYgteshy
(m) ~013H~J05QP 01 ~oolQ2-
(raquo ilygt3dQ~1 mp1 QI3)l)oSl 65T sectSolm dS~~ladQ~
(J) oo~ gt3QID05 d3aQY)~8SaS~ gScoo S~SGam~C~1 IL - Lo L -10 f L Jl l -l tj J
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
(9) ~ol~e
(~) ~~~i~~~~e~~ l(5c8ltS~ (~~ I ~oroon
~ rooSPoS or)) 10100 ~~ QltX)~ ~~cnS~~ )
(-~) ~ol~ie [GenericandBrand name (~~S)]
( G ) ~01 ~Goo~~ (StrengthWeight)
(7) ~~+ltOQOa~ (Dosage )9 G()olo~CIO (Amount)
laquo() GOO 01 ~~ l~~ oY)oo (Duration of use or treatment) I
( ~Xlgs SooSltYXX)d5 ~~coool~ iGOl)1
(a) loS~1
(gt0) roF~~i~1 GOOorXl~~ ~SCl)S ~iOfd5 royen~~~1
(gt0)
( 9 ) ~~~8 (00) (9) i (a) ~~~~d5~ro~p~ ~oSltyen rod5~sect9
Gl~~ ~l3rod5ioS~ ~oSe7S ~al~~11
c=oo~1 ~orcooYgt9 GOOSiJ-gtXl~-(00) ro ~~ ~~ampaOGOO01Qtj~S m))~ n~n i~ro~ampS OON)
IlfJI( iJ -tl- IJ l l---o - T~ -tl- J l Il T-l J
~cS~~p~GgtSrocqj sectl~ J S~c8 d3d5QOYJ~lie II
(s) d~l~P06c~ ~ood5~ll~ ox ~~~8 (00) 01 ~~05~ood5 iJ-gt01~
OOli~1I
I~II ~crr~i~Xl~ shy
(00) ~Td ~9J1oGOO01 ~J-gtsects or))~ ~lttP= or))))~~~oo8 GYgt3fO9 ioSoo~iJ-gtd 4gtSoocqj sectl~ J S ~08 08SQOYJ~l~~1I
(9 ) ~a~3dcxgtaS~ o~ ampl~~(m)ol ~~~oo~ol~~11
(0) ))05~~P 3lt)~l5i 3lt)i3lt)ID~m rooco3lt)OsectS slXlcl laquo~l~
~iOfoS ~3lt)ID~lt8l) ~GOsectSo~ G~li~1I
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
Z oB11 C( ~o~oto d3~iq8~8xgt~ c105o 8[9SGagt I c105QYgtCf05sect [9SGagt 3gtClt(c8~~lo ~ol~Pt9 xY)~~ ~~~lo~ol~p~ 3d~~ gt010gt t9 gtJ ~t93d~ ltMXgt(6rosectS ro~~8 ~a5~ro3droTGay)(rSamp~o5sect9ro~G(YY)8 I cooorxgtP~
roN)~oSoo~ gt3 ~(J)oS d3amplOYJ~ cooon~ ~oSoo~ro3dO~C ro~GaY)8 QC~lOllo50II - J LO L -rto f L Jl J L ~ deg e 0 lj II
~d83d0y)3dOJ8 005~sect81 xgt05~sect8 roo5005oY)sect8t9 ~~sect8 19l~8n~1I
071 oS4aJlampoo19JYoshy
(00) c6oSroSI8rooc s rood38dSn~ o8lCSxgt~ 3d~~coool ~o(i3amp8L L lI L f L L L L L 0 e IIL L J deg
3d~QOO019~6008roOS9d5ampC c8cent0gt8 GCmiddotmo5oY)amploolR~ooScooole J L J J L -lJ- -l 1lC1 IL
~ SoS~~8roGQ)GxY) GOOol~p~8P ~20G3 99 t9 3d~ ~~la~pS1~l ~ cD (~) [99 ooJ~GOG1oiE0~o G~oSCX))1~~H og~l9lrloS 1~ol 00 agtoSJtrooSJtC(oci C(o~81i3dqso5 00~ro20(i3 ~p ampe3d~~3dO~ 6)e~OlI05gt3 ~(J)oS ~clgt6008ro05~oS amploorll ~8amplo5 J deg ~ L 0 deg C1L 11 LO L J L J -l IIW 01
1~~1I
(6) ) lsect~o~ 008~8sect8l9~o~ 008~sect8(Sc~~ C(o~8riXgtel qsectlc0xgt~ 3dBxY)cooo1 ~0G3amp83d~ GQOO1Q~600centooaSg05 G AOOJamploolR
iI L J deg ~ J l J ~ II -L Illf
ttOOScoo01t9 SoS~4P8roGagt~ coo01~p~8P ~eOG3 ~9
93d~~~[9L~aS1~1 ~ (00) sect9 ~~GOG10~E=gt-o G~o5oY) 1~~11 a3~sectlOlJo5 l~oloo ~~G1~ ~n~GP8005G1 O~EC3l~ ol~S ~o~otoS ccagt8 1~~ GOO)8ao51~~ 39l9l~o5sect9 ooc~8 008~Q~ GOO 01 3d~l3dOYJ1 105~13dGro~~1OGOCBgtI 3dG13d06 oS I ~01 ooSOlOlIC3ddSo5 3doc3dro05 ~d5 ~oSoo~ 3dGCOgtoS3dltxygtgn
L 11 L - 0 LO L J 11shy
amp83d00 008081 0088 m ooSod33doo8 ~ltE 3dOYJGnJ05amp8 GooolJ _ tt -0 L-Lj-0 l J bull
~secto~omG1 G0gt5g~~o 3d~18amp l~~11
u) 1~8sect8 I rooSaY)sect~sectlGP8OlJsect8C(oc C(o~8ciXgtel qsectlampXgt~ 3d~lOgtGQ)01~oG3amp8 3d~ G~ 03000e roaSgaSampl oSeogteJ L J c f 1 J J 1
GronoSCX)) ~IR ~ooSGOO01amp8 So-$ ~~roOOGlY) coo01gn088-1- -lJ- -L-ilf It J t LfoAJ ll- L -Lshy
~eOG3 ~p 9~~ ~cent[9t~oS 1~1l qi (e) (99 ~GO~o~~~ Gqw05ltXYgt 1~~1I g~l9lOlJo5(9~ ~GCljY)8n21 ~~otoS (9~ll GP8~ n~ Gabol3d4Ilt3dro ooSy~83drioS 3d083d~o5l 10589 agto5~~ 3dGC)~ir pound IO~CBgtI 3dGampl3dooa5 d5 d3 ~ltE 34C1Ygt3dGnJo5ampd cooolII f -1 -0 Lmiddot L L J bull
[9sectS~oroG1~~~roQ)~rooo~ (7) 1OS3~ 3dSl8~1g~11
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
3q5~ (m) (amp)~ (0) 01 V-0-5~ID~C)05VoSt ~eagtel 01~S ~~l1oS ~sectl~ +~ fuaSot2 ~Dcxx ~~~R~~ot ~o8~ ~~~~I boSouScro8~~ D~l9t~~ogt~
~~roSt~o5rll g]l~~~ 07(00)(~)t~ (o)~01 ~i (~)(e)t~ (gtraquoo~
~ioocb~01~ ScS~~roGQ)cooY) ~01tP P ~t20~POcent~aYJ~~i~psectcb~ell
~~1s)~1f2~gt~oS~~JOamp~OSOgte-(m) ffijoo~2~i~~ o-e-ea [05801 DrroIGYXDcSl ~~lo(Y))ea
d~~~11
(~ diJ~~~~~SJ (~ro~~~o1c0rol~)~ 0 J-oo-Ba
q~01 a~~GY)~oSl G eal GY)~yenoSl3dagtOO0 (0) eaoG071
(0l ~~feggt (3WJ34GOYgtOS ~0106oro~~) (iI~ B-G-JOOO l05~01 ro34ftJoSl 3JagtOO 0 (00) JOoo 0007
(~) d1~~~tamp~ (3dro~~(OO01~~~)~ o~B-JOoo 105801 QYJ3dy03t 3dagtOO 0 (00) 0000JB II
(~) 01 ~o$G31o5OY)Goopsect~
o ltY(I-tQJGloBSJltl
~gt
on ~centc~~~~ g lsectLGl~2~
J n~centC~G3d~~~~S~llGOY)8~~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
x 3d~l3dg ~ ltn ooP~~JlS
~II ~ ~6lJlS~ Gllrol8Q)Ssm
2 o~E)3r)~
OH3d~~O~iol2~SJ
eulampJosect~~8clooSg SJampJlo
gt011 a~J~~lo~~) roaS~aS~2~SJ~~
0011 sect~oS d8 ~~~l2~ggt~IL3r)~
oJ sect~oS o8 3d0Cl6~3fo6lJl0l2~ff-~li~~
OX sect~oS d8sect~~~8c tooog ff-~ll3dJo
0lt1I2~a~ampl~lll~~degr~9rosrO~oScoloc
(sect~~8csect~oo~C8 oo~~89sect~ooollt9 3d~~Wll
~8l(~o)~ g))o~~S~ oo~ 01 l~ ~~oamp6lJ05sect9) d3gt3 oo83dOologtS1lto e
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
bull e~~8fQJt ~4 roo53)~l
ooJ~~Glo~~~
Gt~eCD4Y)3O)GgtYgtltJS~ ~ol~ltD)~~3)~
~3)tYgt~~~ Ga)ol~secto06ocOl GltYgt5Q~
3Jltllc8QJL8~olQJt JY)Q03QJL~coolQr
rooS~ cP~QJl~gLQJoS
~s~~~~~~___-_-_-----_-_-- a08~I-----------------shy~ - J -l 0
~~3dltlY)3dGJY)oS~ G6O01 ~sectoos8roGlGr05~~X)~ ooJ~~Gl
o~aosect ~(x)~Gro01 ~ 2ro~4P~roGox)Y) GroO1~Jgtc8ltiijl0l~centP 3d8 ~~~ J 01
~~~~~S06S ~01or8c~ ~I ~g~c)~1 ltsectL~3iY) ~secto1 ~~c8+ltiijl8 Gro01~Jgt
~)Y)~~c8~crto ~01aJgt~~~8t~ ~~~ B~loo08ti5 ~~~g~a~08 oto5oo yenx)~1I
~u or8c+ S13I~3dc)~1 ltsectL~~G~~ c88ro ------------------------------- shy
---------------------------------------------------------------------shy
JII ~~ltiijG~GOOot ~~~~ ooaP c8oro -----------------------------------
~Q G4ipcent~lG~G6001~~~ [GenericandBmndname(~t)]----------------------shy
911 ~~sectlX)~ gt)03oo~(JY)oo ( ) SI X)08oo~O~a~ 9108 --~------------------shy
~a ~~f9t~08l~~))~~~roltXYgtX)~ ~ltX(c8~loGOO01aJgtsect ~c8O)JoGOO01 GJgt [ 1
oo08~ ~sJl~S~SP ltD~oo~~08~~ a08fXl~~1I
oco6Gro-------~--------------shyJ
-------__------__-__----__------__-------_ ----------_- shy
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
-----------------
------------------ ----
---------------------------------_-
~c~centl84GOt centccm53l~ ~QOCfdegt~a-gt
lY4~2c3larn~~ coo1~2g)i
ampoSg)fY)3)~~ ~o1sectolt1J~mcl ccnamp9~
gtYgt9icB QJLo~o1 QP ro05c8~QrtJ g~sectLQJOS
89a~~-------------- lOS~I------------_----------
~loS 3) GYgt 3) GgtY)05 ~ GOO 01 ~(sect006Oro GlGr05~d3o)e ooJ~=YgtGl
o~3ggt~ ~ooS~01~ ga5~~8roooGlY) ltooo1QPc8~gJloGl~8P 3)B~ 3)~~ G
~l ~0501 C(OCI 5I33g33Q)~1 ~sectlcS33) GCJ5sectol mQc8iIl8Groo1QaP~ 0005lt8
GP8~l~ g~sectL~oS CX(a5go~oS)J~1I
011 C(8c~ ~ l33g33Q)2 I sectLa33dQ2t~ aSOro---------------------------------shy
JII ~cent~~elGro~cent 3dQ~t~ ())~Pd38ro ---------------------------------shy
~II GfJcent~lQellOOo1 3dQ~ [GenericandBrandname(~)]-----------------------
---------------------------------------------------------------------~-
7 g~sectLOel oOS~(YY)oo ( ) SI o05O)~or~Qel tloS ----------------------shy
t)1I 8~sectL~oSl~~)J~ oa5yoSrogt)Jel ~Q~c8~~[8 lt0001 Qp coOSd5 G~~sect8~8P
Q)~ro~~aPc8 aS05cfO l9~ II l L~ t
LA
I
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
~ I
I II I I I II I i I IIshy I II I II I I I I I I f I I
I II I jI I iI I I i
I I I I I I I vn Io I I I
I
VBy -(u
I 8 J)fll I I I
I
-- I -r I 8 I I e I I I I I r G8 I I I I 3Xgt J I C I I (It I I OJ I I 8 I I gt JI I I G I (18 I I I g-- I I I I I I t- I I ow I I I ~ I I v I
~ ~ I I lt(t] I I 0 I I 0 I I vI) I I 0 I
I CO I II I HJa j lt0-- I I I I -- J I I) I
~ ~II lt1 I 00 I
middot0 gtlt(10 J Q J
O~ ~ I S I I
(Igt I la I08 I ~ J lt) I l-- I
(p I d I lt13- a I(jI ~ I
~ jI - I I I
I aJ I I 3l J
fl 0 I
fi o
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~
~
0
lt
(
0 C
C
0
C
C (
C
C
(
ltgt
Co
ro~ltiRO~OI
G
~JL=
G
qY)
0
01
qjC
r)
C-
f m
O())otG~Cqjl3C
C00
2 3
d0
QC
()
0)
CC
~
0 C
l
0
C
0 C
bull
0 C
Cc
C 0
C C-
Oli
f69t3L6lJm91l~ 3dg~1
Gtl
()CO
()qY
)1
1CC
O
)
0Q)0GqmO)l)3d~01 GOO~C3d0~ -----------------------------------shy
~ (
C
o
c
lt lt
C
0 lt
-O
C-
JIi
~
ol3
d~~
[(G
ener
ic a
nd B
raIld
nam
e) (~c
xJ6
)Jf
9 oC02X3dGC0fj~loro~(JOelo(~mI0mI~(C302---------
--------
ltgt
~
C
c I
I 3d
0lC
6l
))~
CO
l f(lt
0
~-------------------------~--~----------------------
Oll~mIc)Cb~ I
6
lQG
lj 2
C~middot-l
0 1
l
(d
q]1
lt
D
~
r
)~~
I Imiddot
I I
t I I
I _LI __
____
____
~ )~=tc ---------------~----~