A prescription issued pursuant to this article must be substantially in the following form: "State of South Carolina – County. To – druggist. I, -, a regular licensed and practicing physician under the laws of this State, do hereby certify that I have examined -, a patient in my charge, and I do hereby prescribe for the use of the patient – alcohol. I further certify that the use of this alcohol is, in my judgment, absolutely necessary to alleviate or cure the illness or disease from which the patient is now suffering and that I am not interested in the drugstore to which this prescription is directed nor in the profits on the drugs herein prescribed.

Dated –. — M. D."