Utilization Certificate Form: Required for Issuance of Restricted Medicine from CGHS Utilization Certificate This is to certify that ... ... ... ...

Utilization Certificate Form: Required for Issuance of Restricted Medicine from CGHS

### Utilization Certificate

This is to certify that … … … … … … … … … … … … … … (Name of Medicines, quantity, dose, frequency) … … … … … … … … … … … … …  issued to … … … … … … … … … … … … … … (Name & Token No of Patient /Name of Dispensary) issued on… … … … … … … … … (Date of issue) has been utilized /will be utilized by(Date) … … … … … … … If required empty strips/vials will be submitted.

 Signature of Patient Token No: Address & Telephone No Signature of the Specialist/ CMO Date:- Stamp

Counter Signature of CMO I/C WC with Stamp

### View: CGHS: Instructions for Issuance of Restricted Medicines

[https://cghs.gov.in/showfile.php?lid=6216]