Said prescription shall state the disease or ailment from which the patient is suffering and shall prescribe the method of the use or administration of said alcohol and the quantity of the dose or doses to be taken and the intervals between doses or the time when the same are to be administered. The prescription shall state and certify that the use of such alcohol, in the opinion of the physician, is necessary to alleviate or cure the illness or disease from which such patient is suffering. Every such prescription shall contain the name and address of the physician giving the prescription, the name and address of the person for whom the alcohol is prescribed and the date on which the prescription is written and shall state the number of prescriptions for alcohol which the physician has written for said patient within 12 months or that he has not written any within that period for said patient.