FORM ‘C’

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/buckfast 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/champagne 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/buckfast 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

^* 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.

¹ Subs. by G. N. of 30-6-1958.