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["Załącznik nr 3/1.2               "]
["nr sprawy ZP.12.PN.2017"]
["FORMULARZ ASORTYMENTOWO-CENOWY"]
["(zamawiający zastrzega sobie prawo do zakupu mniejszych ilości towaru)"]
[null,"Nazwa asortymentu","dawka","postać leku","J.m.","Ilość","Uwagi","Cena jedn. Netto (zł)","Wart. netto (zł)","VAT %","VAT (zł)","Wartość brutto (zł)"]
[1,"deksametazon","4mg/1ml","inj.","op.",8]
[2,"deksametazon","8mg/2ml","inj.","op.",14]
[3,"hydrokortyzon","25mg/1ml","roztw.do wstrzykiwań","op.",1,"hemisuccinatum"]
[4,"lewotyroksyna","50mcg","tabl.","op.",29]
[5,"lewotyroksyna","25mcg","tabl.","op.",1]
[6,"lewotyroksyna","100mcg","tabl.","op.",17]
[7,"prednizon","5mg","tabl.","op.",2,"op.20szt"]
[8,"prednizon","10mg","tabl.","op.",10]
[9,"tiamazol","5 mg","tabl.","op.",20]
[10,"hydrokortyzon","100mg/2ml","roztw.do wstrzykiwań","op.",20]
[11,"tiamazol","10 mg","tab.","op.",1]
[12,"tiamazol","20 mg","tab.","op.",1]
[13,"metyloprednizolon","4 mg","tabl.","op.",1]
[14,"metyloprednizolon","16 mg","tabl.","op.",10]
[{"$nulls":4},"Razem (zł)"]
["SŁOWNIE (zŁ)"]
[]
["Netto:…………………………………………………………………………………………………………………….........................                                                 "]
[]
["VAT:……………………………………………………………………………………………………………………..........................."]
[]
["Brutto:…………………………………………………………………………………………………………………............................"]
[]
[{"$nulls":7},"………………………………………………"]
[{"$nulls":7},"Pieczęć i podpis wykonawcy"]