Mind and its disorders : a text-book for students and practitioners / by W.H.B. Stoddart.

  • W.H.B. Stoddart
Date:
1908
Catalogue details

Licence: In copyright

Credit: Mind and its disorders : a text-book for students and practitioners / by W.H.B. Stoddart. Source: Wellcome Collection.

Provider: This material has been provided by King’s College London. The original may be consulted at King’s College London.

    510/562 (page 468)
    53 Vict., c. 5, Sched. 2, Forms 4, 2, 8, and 9. Form of Urgency Order for the Reception of a Private Patient, with Medical Certificate and Statement accompanying Urgency Order. 3-, the undersigned, being a Person Twenty-one years of age, hereby authorize you to receive as a Patient into (a) House, or hos- , , pita], or asylum, as your [a), a single patient. (b) Name of patient, [b) (c) Lunatic, or an idiot, or a person of as a (c) unsound mind. saw at_ .whom I last _day of_ -19- (d) Some day within the (d) two days before the date of the Order. 5 am not related to or connected with the Person signing the Certificate which accompanies this Order in ye) Husband, wife, any of the ways mentioned in the Margin, [e) Sub- father, fattier-in-law, mother, mother-in- joined or annexed hereto is a Statement of Particulars law, son, son-in-law, daughter, daughter- j-glating to the said in-law, brother, o brother-in-law, sister, sister-in-law, partner, or assistant. [// not the husband or wife, or a relative of the patient, the person signing to state as briefly as possible:—■ I. Why the Order is not signed by the husband or wife, or a relative of the patient. 2. His or her connection with the patient, and the circumstances under which he or she signs.] (SigneD) Name and Clmstian Name') at length - - - -J Rank, Profession, or Occupa-'\ Hon {if any) - - -J FtiU Postal Address - - . How related to or connected') with the Patient - -/ (/) Superintepfient of the asy- lum, hospital, or resident licensee of the house [de- scribing the asylum, hospital, or house by situation and name.] H)atcC) this. .day of. -19- To (/).