FORM

FORM

[See rules 92,93,94 and 94A]

Prescription of Registered Medical Practitioner for Port-wine/port-type wine/wincamis/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 port-wine/port-type wine/wincamis/vibrona/manola/buckfast tonic wine/champagne is issued.
4. Nature of the person's illness or pain for which port-wine/port-type wine/wincamis/vibrona/manola/buckfast tonic wine/champagne is prescribed.
5. ^*Quantity of port-wine/port type wine/wincamis/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/wincamis/vibrona/manola/buckfast tonic wine/champagne is to be taken.
7. Total quantity of port-wine/port-type wine/wincamis/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.

1 Subs. by G.N. of 30-6-1958.