Polaris 3900 Sport/P39 Owner's Manual page 1157

Hide thumbs Also See for 3900 Sport/P39:

Example Forms/Labels

This person is now living at:-

....................................................................................................

*Delete the words which do not apply.

If supplying drugs

*a. Where I agree to visit him/her when necessary.

*b. Where I do not agree to visit him/her. and I hereby give notice that I

wish to terminate responsibility for him/her.

Signature...........................................................

Enter 'D' here

Registration Reference Manual

(for completion by Doctor)

If claiming a rural

practice payment

Enter distance from main

surgery to patient's

residence and inform HA if

claiming for other than

ordinary distance

Version: 2.13