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
- Prescription No. Date
- Registered Medical Practitioner
- Name
[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
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.
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