{{prescriber.name}}

{{prescriber.qualification}}

{{prescriber.registration}}

{{prescriber.address}}

{% if prescriber.contact %}Contact: {{prescriber.contact}}{% endif %}

{{prescriber.extra}}
{% if age %} {% else %} {% endif %}
{% if id %}ID: {{id}}{% endif %}

Name: {{name}}

Sex: {{sex}}

Age: {{age}}

Date of Birth: {{dob}}

{% if address %}Address: {{address}}{% endif %} {% if contact %}Contact: {{contact}}{% endif %}
{% if diagnosis %}Provisional Diagnosis: {{diagnosis}}{% endif %}

{{certificate}}
{% if mode %}Consultation: {{mode}}{% endif %}
{% if daw %}Dispense as written{% endif %}

{{date.strftime("%B %d, %Y %I:%M %p")}}

Signature