Republic of the Philippines

DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

FORM 1
REQUISITION ISSUANCE SLIP (RIS)
2023 MENTAL HEALTH MEDICINES
ACCESS PROGRAM

Name of Health Facility: Contact No.: _________________________

Address:

Quan Total Target Number of Patients for the year 2024

tity *Nu
for 1 mber
Psyc year of
hotr consu Patie
opic mptio nts
n+ using
Med
3- the
icine mont medi
s h cine
buffe
r
stock
Carb
ama
zepi
ne
1.
200
mg
Tabl
et
Lithi
um
Carb
onat
e
2.
450
mg
MR
Tabl
et
Diva
lproe
x
Sodi
um
3.
250
mg
ER
table
t

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

Sodi
um
Valp
roate
4. 250
mg/5
ml
Syru
p
Diva
lproe
x
Sodi
um
5.
500
mg
ER
table
t
Sodi
um
Valp
roate
+
Valp
roic
Acid
500
mg
(333
mg
sodi
um
6.
valpr
oate
+
145
mg
valpr
oic
acid)
contr
olled
relea
se
table
t
7. Bipe
riden

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

Hydr
ochl
oride
2 mg
Tabl
et
Chlo
rpro
mazi
ne
8.
200
mg
Tabl
et
Cloz
apin
e
9. 100
mg
Tabl
et
Flup
hena
zine
Deca
noat
e 25
10.
mg/
mL,
1
mL
Amp
oule
Diph
enhy
dram
ine
11. 50
mg/
ml
amp
oule
Halo
perid
ol 5
12.
mg
Tabl
et

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

Halo
perid
ol 5
mg/
13. mL,
1
mL
Amp
oule
Olan
zapi
ne
14. 10
mg
Tabl
et
Olan
zapi
ne
10
mg
Oro-
15. Disp
ersib
le
Tabl
et
(OD
T)
Quet
iapin
e
16. 200
mg
Tabl
et
Risp
erido
ne 2
17.
mg
Tabl
et
18. Risp
erido
ne 2
mg
Oro-
disp
ersib

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

le
Tabl
et
(OD
T)
Escit
alopr
am
19. 10
mg
Tabl
et
Fluo
xetin
e 20
20.
mg
Caps
ule
Sertr
aline
50
21.
mg
Tabl
et
Lam
otrig
ine
22. 100
mg
Tabl
et
Don
epez
il 10
23.
mg
Tabl
et
Flup
henti
xol
24.
20
mg/
ml
25. Palip
erido
ne
Palm
itate
150

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

mg
prefi
lled
syrin
ges
Palip
erido
ne
Palm
itate
26. 100
mg
prefi
lled
syrin
ges
Me
mant
ine
27. 10
mg
table
t
Leve
tirac
etam
28. 500
mg
table
t
Oxc
arba
zepi
ne
29.
300
mg
table
t
30. Oxc
arba
zepi
ne
60
mg/
mL,
100
mL

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

oral
susp
ensi
on
31. Oth
er
med
icine
/s:
(Kin
dly
spec
ify)

Previous number of patients served with the following mental health conditions (2022):
Di Male Female
ag 5- 13-
60 yrs 5-12 60 yrs
nos 0-1 2-4 12 19 40-59 0-1 2-4 13-19 20-39 40-59
old and yrs old and
yr old yrs old yrs yrs yrs old yr old yrs old yrs old yrs old yrs old
is above old above
old old
Ps
yc
hos
is
(Sc
hiz
op
hre
nia
)
An
xie
ty
Dis
or
der
s
Mo
od
Dis
or
der
s
De
me
nti
a

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

Ep
ile
psy
Su
bst
an
ce
Ab
use
Dis
or
der
s

Ot
her
dia
gn
osi
s
(pl
eas
e
spe
cif
y):

******************************************************************************************************************
Prepared by: Approved by:
Si
gn
at
ur
e:
N
a
m
e:
De
sig
na
tio
n:
C
on
ta
ct
N
o.:

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTRAL LUZON CENTER FOR HEALTH DEVELOPMENT
Maalaga St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San Fernando, Pampanga
Tel no. (045) 861-3425 to 29│website: https://centralluzon.doh.gov.ph│email address: [email protected]

E
m
ail
A
dd
re
ss:

Vision: Mission: Core Values:

A dependable LEADER in health. Guarantee access to quality health Compassion Integrity
care in Central Luzon that is Sensitive to the needs and feelings of Exhibits honesty, accountability and
responsive, equitable and resilient. others consistency in performing our duties.
Teamwork ISO 9001:2015
Excellence
No. SCP000549Q