[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.