ORDER FORM

Pharmacy Stock Order Form – Kenya

Pharmacy Stock Order Form

Supplier Details

Supplier Name

PPB Wholesale License Number

Address / Contact

Pharmacy / Facility Details

Pharmacy / Facility Name

PPB Premises Registration Number

Physical Address

County

Annual Practice License Number

Superintendent Pharmacist / Pharm. Technologist

PPB Registration Number (Pharmacist/Technologist)

Contact Number

Email Address

Order Information

Order Number (Supplier assigned)

Order Date

Requested Delivery Date

Source of Funds (if applicable)

Items Ordered

List items from KEML / KEMSL or registered products only. Attach PPB permits for controlled drugs.

#	Product Code	Generic Name & Strength	Dosage Form	Pack Size	Qty Ordered	Unit Price (KES)	Total (KES)
1
2
Grand Total (KES)

Controlled / Restricted Substances (if applicable)

Item(s)

PPB Authorization / Permit Number

Supporting documents attached

Delivery Instructions

Delivery Address (if different)

Special Requirements (cold chain, etc.)

Important Terms & Compliance Notes
• All products must comply with Pharmacy and Poisons Act (CAP 244), PPB GDP Guidelines, and be from approved lists (KEML/KEMSL).
• Short-dated stock (< 1/3 shelf life) not accepted unless pre-approved.
• Full batch, expiry, and CoA documentation required on delivery.
• Records maintained for audit, traceability & pharmacovigilance.

Ordered By (Superintendent Pharmacist / Pharm. Technologist)

Approved By (if required)

Supplier Acknowledgment

For official use: Retain copies. Reconcile with delivery note (quantity, batch, expiry, condition). For public facilities – align with KEMSA schedules and use RIRV where applicable. Always refer to latest PPB guidelines.