Digicon

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@csrf

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(Kindly fill in the relevant information or tick, as appropriate.)

@if (isset(session()->get('doctor')['vCentralCode']))

Name*

@else

Name*

@endif

ID No. *

Initials *

Gender *

Male Female

Age (in Years) *

Weight (kg)*

Pharyngitis

Tonsillitis

Acute Otitis Media

Acute Sinusitis

Gingivitis

Dental abscess

Dental caries

Periodontitis

Skin and Skin Structure Infections

Other indication

Treatment Details
Drug Name	Dose	Frequency
Drug Name	Dose	BID	TID
MOXCLAV 625 mg tablet (500 mg + 125 mg)^$		BID	TID
MOXCLAV BD syrup (200 mg + 28.5 mg per 5 ml)^$		BID	TID
MOXCLAV BD distab (200 mg + 28.5 mg)^$		BID	TID
MOXCLAV DS syrup (400 mg + 57 mg per 5 ml)^$		BID	TID
MOXCLAV DS distab (400 mg + 57 mg)^$		BID	TID
($: Amoxicillin + Clavulanic acid)

Duration of treatment *

5 Days 7 Days 10 Days 14 Days Other

Clinical cure * Clinical improvement ** Clinical failure ***