Retail Chemist Prescription Audit

CHEMIST SURVEY REPORT NAME OF B E TOWN -

DAT E-

NAME OF CHEMIST -

ADDRESS -

CONTACT PERSON -

PHONE NO -

PRODUCT SELECTED FOR RCPA:COMP. BRAND NAME

COMPANY

PRESCRIBER DR. NAME

ARE A

QUL./S PL

APPROX. QTY SALE / WEEK

STOCKIST COVERED

QUL./S PL

APPROX. QTY SALE / WEEK

STOCKIST COVERED

PRODUCT SELECTED FOR RCPA:COMP. BRAND NAME

COMPANY

PRESCRIBER DR. NAME

ARE A