SCHEDULE (F), No. 2. Order for the Reception of a Private Patient. I, the undersigned, hereby request you to receive A.B., a lunatic [or an idiot, or a person of unsound mind], as a patient into your asylum. Subjoined is a statement respecting the said A.B. Dated this Το borough] of superintendent of the asylum for the county [or [describing the asylum]. STATEMENT. [If any of the Particulars in this Statement be not known, the Fact to be so stated.] Name of patient, with christian name, at length. Sex and age. Married, single, or widowed. Condition of life, and previous occupation (if any). The religious persuasion, as far as known. Previous place of abode. Whether first attack. Age (if known) on first attack. When and where previously under care and treatment. Duration of existing attack. Supposed cause. Whether subject to epilepsy. Whether suicidal. Whether dangerous to others. Whether found lunatic by inquisition, and date of commission or order for inquisition. Special circumstances (if any) preventing the patient being examined, before admission, separately by two medical practitioners. Where the person signing the statement is not the person who signs the order, the following particulars concerning the person signing the statement are to be added, viz.: Occupation (if any). Degree of relationship (if any), SCHEDULE (F), No. 3. Form of Medical Certificate. day of at I, the undersigned [here set forth the qualification entitling the person certifying to practise as a physician, surgeon, or apothecary, ex. gra., being a fellow of the royal college of physicians in London], and being in actual practice as a [physician, surgeon, or apothecary, as the case may be], hereby certify, That I, on the [here insert the street and number of the house (if any) or other like particulars], in the county of [in any case where more than one medical certificate is required by this Act, here insert separately from any other medical practitioner] personally examined A.B. of [insert residence and profession or occupation, if any], and that the said A.B. is a lunatic [or an idiot, or a person of unsound mind], and a proper person to be taken charge of and detained under care and treatment, and that I have formed this opinion upon the following grounds, viz.: 1. Facts indicating insanity observed by myself [here state the facts]. 2. Other facts (if any) indicating insanity communicated to me by others [here state the information, and from whom]. (Signed) Place of abode. SCHEDULE (F), No. 4. Notice of Admission. I hereby give you notice, that A.B. was admitted into this asylum as a private [or pauper] patient on the day of and I hereby transmit a copy of the order and statement and medical certificates [or certificate] on which he was received. [If a private patient be received upon one certificate only, the special circumstances which have prevented the patient from being examined by two medical practitioners to be here stated, as in the statement accompanying the order for admission.] Subjoined is a statement with respect to the mental and bodily condition of the above-named patient. Dated the day of (Signed) asylum. STATEMENT. I have this day [some day not less than two clear days after the admission of the patient] seen and examined the patient mentioned in the above notice, and hereby certify that with respect to mental state he [or she], and that with respect to bodily health and condition he [or she] Form of Notice of Discharge, Removal, or Death. I hereby give you notice, that patient admitted into this asylum on the pauper [or a private] day of was discharged therefrom recovered [or relieved, or not improved], or was removed to [mentioning the asylum, etc.] relieved [or not improved], by the authority of therein in the presence of ], on the (Signed) , [or died day of asylum. In case of death, add, "I certify that the apparent cause of Registry and Admission.-Register of Patients. SCHEDULE (G) No. 2. Register of Discharge, Removal and Deaths. * In the case of an asylum receiving both pauper and private patients, a separate journal to be kept in the above form for each class. ACT TO AMEND THE LUNATIC ASYLUMS ACT, 1883. 18 & 19 Vict., ch. 105; Chitty, vol. 3, p. 197. $1. Any county may unite with subscrib 274. Section 3 of the Lunatic Asylums Act, 1853, shall extend to empower the justices of any one county or borough to authorise any committee of justices elected for such county or borough thereunder to treat and ers to asylum. enter into an agreement for uniting with the subscribers to any such hospital as therein mentioned, and it shall not be necessary that any other county or borough be a party to such agreement; and section 5 of the said Act shall extend to empower any such committee of visitors as therein mentioned, and it shall not be necessary to enter into an agreement for uniting with the subscribers to any such hospital alone. 275. [§ 2. The proportion of expenses between any county and borough may be fixed with reference to accommodation likely to be required.] 276. [§ 3. Agreements for uniting to be hereafter entered into to stipulate for contribution by counties and boroughs according to their relative populations for the time being, where not fixed according to foregoing provision.] 277. [§ 4. Where expenses are to be contributed in proportion to population, the same to be ascertained by last census for the time being.] 278. [§ 5. Where there is a dissolution of a union a new asylum to be provided.] 279. [§ 6. Provisions to apply to councils of boroughs where they have taken upon themselves the execution of the Lunatic Asylums Act, 1853.] 280. [§ 7. Places becoming boroughs after the commencement of the Lunatic Asylums Act, 1853, to be deemed boroughs annexed to the counties in which they are situate.] § 8. Visitors may remove pauper lunatics 281. The power given by section 77 of the Lunatic Asylums Act, 1853, to any two of the visitors of any asylum, being justices, to order any pauper lunatic chargeable to any parish or union within the county or to proper borough, or any county or borough to which such asylum wholly or in part belongs, or to any such county, and who may be confined in any other asylum, or in any regis asylum. |