KUMC Department of Pharmacy
Formulary Admission Form Request
THE UNIVERSITY OF KANSAS MEDICAL CENTER
UNIVERSITY OF KANSAS HOSPITAL
PHARMACY AND THERAPEUTICS COMMITTEE
All sections of this application must be completed by the physician making this request. The Pharmacy and Therapeutics Committee will consider this application at their next scheduled meeting.
Proprietary Names/Manufacturer(s):
Dosage Form(s) Requested
Estimated Usage:
Please state briefly what advantage(s) this preparation has over any preparation currently in the KUMC FORMULARY
Please list applicable controlled clinical drug studies
that substantiate the superiority of this product and enclose a reprint of the most
important article(s) supporting this application:
If this agent is added, what drug(s) do you
recommend be replaced in the KUMC FORMULARY:
Do you recommend that this drug be restricted as a
Formulary product, and if so, to what service(s) or specific patient condition(s):
Please identify the economic impact to the
patient/hospital that this agent would have compared to current therapeutic practices
(describe current costs vs proposed costs):
In the last three years, have you participated in
any manufacturer or competing manufacturer sponsored research, clinical trials, or invited
presentations regarding this manufacturer?
If yes, please describe:
Submittor's Name (attending Physician/Department)
Department/Division
Submittor's e-mail address
Department Chairman
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