[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