FORM ‘C’
Prescription of Registered Medical Practioner for 1 [Port-wine/port-type wine/wincarnis/vibronal/monolal/buckfast/tonic wine/ champagne]
See rules 92, 93, 94 and 94A
FORM 'C' is a medical prescription certificate used to authorise a patient to obtain port-wine, port-type wine, wincarnis, vibronal, monolal, buckfast tonic wine or champagne for an illness or pain. It is issued by a Registered Medical Practitioner who certifies that he has been the patient's family physician for more than a year. The form records the daily quantity and the number of days of use, subject to prescribed limits: one quart bottle a week for the wines, or one pint bottle a day for champagne, and a maximum of thirty days for the wines or fifteen days for champagne. It is authorised by rules 92, 93, 94 and 94A of the Bombay Foreign Liquor Rules, 1953.
800 Bombay Prohibition Act, 1949 [1949 : Bom. XXV FORM ‘C’ [See rules 92, 93, 94 and 94A] Prescription of Registered Medical Practioner for 1 [Port-wine/port-type wine/wincarnis/vibronal/monolal/buckfast/tonic wine/ champagne] 1.Prescription No. Date 2.Registered Medical Practitioner Name . . . . . . Address . . . . . . Registered No.. . . . . . 3.Name and address of the person in whose favour the prescription for portwine/port- type wine/wincarnis/vibrona/manola/buck fast tonic wine/champagne is issued. 4.Nature of the persons illness or pain for which port-wine/port-type wine/wincarnis/ vibrona/manola/buckfast tonic wine/cham- pagne is prescribed. 5.*Quantity of port-wine/port type wine/ wincarnis/vibrona/manola/buckfast tonic wine/champagne to be taken in day for the above illness or pain. 6.Number of days for which port† wine/port type wine/wincarnis/vibrona/manola/buck fast tonic wine/champagne is to be taken. 7.Total quantity of port-wine/port-type wine/ wincarnis/vibrona/manola/buckfast tonic wine/champagne prescribed for the above period. I hereby certify that, I am the family physician for more than a year of the above named. Mr./Mrs./Miss Shri/Shrimati/Kumari Signature of the Registered Medical Practitioner. *The quantity may be so prescribed that it shall not exceed the rate of the one quart bottle in a week in the case of port-wine, port-type wine, wincarnis vibrona, manola and buckfast tonic wine or one pin bottle in a day in the case of champagne. †This period should not in any case exceed thirty days in the case of port-wine, port-type wine, type wincarnis vibrona, manola and buckfast tonic wine or fifteen days in the case of champagne. 1Subs. by G. N. of 30-6-1958.