A bill intituled An act to amend the acts relating to lunatics.

Date:
1886
Catalogue details

Licence: Public Domain Mark

Credit: A bill intituled An act to amend the acts relating to lunatics. Source: Wellcome Collection.

Provider: This material has been provided by Royal College of Physicians, London. The original may be consulted at Royal College of Physicians, London.

    55/64 (page 47)
    Form 4. A.D. 1886. Form of urgency Order for the reception of a private patient. 5 10 15 20 I, the undersigned, being a person twenty-one years of age, hereby authorise you to receive as a patient into your house [x] A.B., a lunatic [2], whom I last saw at on the [3] day of 18 . I am not related to or connected with the person signing the certificate which accompanies this order in any of the ways mentioned in the margin [*]. Sub- joined [or annexed] hereto [5] is a statement of particulars relating to the said A.B. (Signed) Name Rank or profession (if any) Full postal address Degree of relationship (by blood or marriage) to patient [If not a relative, the person signing to state as briefly as possible: 1. Why the order is not signed by a relative. 2. His connexion with or interest (if any) in the patient, or the circumstances inducing him or her to sign.] Dated this day of 18 . To , proprietor or superintendent of house [6] [or hospital or asylum]. [‘] Or hospital, or asylum or as a single patient. [2] Or an idiot, or a person of unsound mind. [3] Some day within seven days before the date of the order. [4] Husband, wife, father, father-in-law, mother, mother-in-law, son, son-in-law, daughter, daughter-in- law, brother, brother-in-law, sister, sister-in- law, partner, or assistant. [“] See Form 2. [6] Describing house or hos- pital or asylum by situation and name.