Section 30E. Every retail pharmacist licensed under section thirty A shall keep a book in which he shall enter, at the time of every such sale, the date thereof, the name of the purchaser, the kind, quantity and price of said beverage, the purpose for which it was sold, and the residence by street and number if any, of said purchaser. If such sale is made upon the prescription of a physician, the book shall also contain the name of the physician and shall state the use for which said beverage is prescribed and the quantity to be used for such purpose, and the prescription shall be cancelled in the manner provided in the preceding section with reference to certificates. Said book shall be in form substantially as follows:
The certificate mentioned in the preceding section shall be a part of said book and shall not be detached therefrom, and shall be in form substantially as follows:
I wish to purchase....... and I certify that I am not a person under age twenty-one and that the same is to be used for *Mechanical *Chemical *Medicinal purpose.
(*Draw a line through the words which do not indicate the purpose of the purchase.)