《麻醉药品、第一类精神药品购用印签卡》申请表

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1、《麻醉药品、第一类精神药品购用印签卡》申请表医疗机构名称医疗机构代码 地址 电话号码邮政编码床位数平均日门诊量具有麻醉药品、第一类精神药品处方权职业医师数量     医疗机构公章：       年月日药学部门负责人签章 医疗机构法定代表人（负责人）签章  批准单位意见      审核人签字：（公章） 年月日theprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequ

2、alityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic7医疗机构《麻醉药品、第一类精神药品购用印鉴卡》变更申请表医疗机构名称（章）法定代表人（主要负责人）（章）申请日期年月日填写日期年月日成都市卫生局制theprovisionsofelectricpowerconstructionenginee

3、ringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic7（一）申请变更事项项目原核准事项申请变更事项医疗机构名称医疗机构地址医疗机构负责

4、人医疗管理部门负责人药学部门负责人采购人员及身份证号码医疗机构公章处方权医师备注：theprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>9

5、9%,andweldbeadappearance;2.4.1.3boilerhydraulic7（二）变更理由及材料申请变更理由提交的资料区（市）县卫生局意见年月日注：区（市）县注册医疗单位需所在地区（市）县卫生局签字并加盖公章，市卫生局注册单位不需区（市）县卫生局签署意见。theprovisionsofelectricpowerconstructionengineeringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationo

6、fatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic7(三)受理、审查、核准医疗机构变更登记受理人员意见受理通知编号：签字：年月日审查(调查、核实)人员意见签字：年月日主审人意见签字：年月日主管领导意见签字：年月日局长核批签字：年月日theprovisionsofelectricpowerconstructionengine

7、eringqualitysupervisionandquality...2.4.1.1theunitworksacceptancerateof100%,thequalityevaluationofatotalscoreof95orabove;2.4.1.2regulatedWeldingNDTinspection100%,regulatedweldingapassingrateof>99%,andweldbeadappearance;2.4.1.3boilerhydraulic7授予执业医师特殊药品处方资格人员花名册单位（签章）:编号姓名性别年龄科别职称执

8、业类别执业级别执业范围变更事项考核成绩备注审核批准负责人:填表人: