Clerk of the Peace.

Note.-Fourteen days' previous notice of the intention to renew this licence must be given to the clerk of the metropolitan commissioners or clerk of the peace.

SCHEDULE (B.)

STATEMENT and ORDER to be annexed to the Medical Certificates authorizing the Reception of an Insane Person.

The patient's true christian and surname

at full length

The patient's age
Married or single

:}

The patient's previous occupation (if)

any)

The patient's previous place of abode The licensed house or other place (if any) in which the patient was before confined

Whether found lunatic by inquisition, and date of commission

Special circumstance which shall prevent the patient being separately examined by two medical practitioners

Special circumstance which exists to prevent the insertion of any of the above particulars

Sir,

UPON the authority of the above statement, and the annexed medical certificates, I request you will receive the said as a patient into your house.

To Mr.
Proprietor of

Name

I am, sir,

Your obedient servant,

Occupation (if any)

Place of abode

Degree of relationship (if any)

to the insane persons

SCHEDULE (C.)

FORM of MEDICAL CERTIFICATES.

I, the undersigned, hereby certify, That I separately visited and per

sonally examined

annexed statement and order, on the

the person named in the

day of

No. IV.

2 & 3 W. 4,

c. 107.

Lunatics.

one thousand eight hundred and

be confined.

[Part VI. and that the

is of unsound mind, and a proper person to

Physician, surgeon, or}

apothecary

Place of abode

I, the undersigned, hereby certify, That I separately visited and per

sonally examined

the person named in the

day of

and that the

is of unsound mind, and a proper person to be

FORM of ORDER by Justice of Peace in Cases of Pauper Lunatics.

to wit. }

that

WHEREAS it appears to me,

of his Majesty's justices of the peace in and for the having called to my assistance Mr.

chargeable to the parish of

in the

said county, is of unsound mind, you are hereby directed to cause the

FORM of ORDER by Officiating Clergyman and One Overseer of the

Parish.

WHEREAS it appears to us, the undersigned, being the officiating clergyman of the parish of and one of the overseers of the poor of the said parish of having called to our assistance A. B. [physician, surgeon, or apothecary], that E. K., chargeable to the parish of is of unsound mind, and

a proper person to be received into a house licensed for the reception of insane persons, we request you to receive the said E. K. into your licensed house.

(Signed)

Officiating Clergyman.
Overseer.

SCHEDULE (F.)

FORM of MEDICAL CERTIFICATE in the above Cases.

I DO hereby certify, That by the directions of justice of the peace in and for the county of

the reverend

minister and

said

overseer] I have personally examined the

of the parish of

and that the said

[or officiating

is of unsound

one thousand eight

Physician,
Surgeon,

No. IV.

2 & 3 W. 4,

c. 107.

or

Apothecary.

I AM to acquaint you, That

was received into my house on the

day of

and I herewith transmit a copy of the order and medical certificates.

FORM of NOTICE on Discharge, Removal, or Death of Patient.

SCHEDULE (I.)

MEDICAL JOURNAL and WEEKLY STATEMENT to be kept in each licensed House for the Inspection of Commissioners or Visitors.

General Re

Names of Names of No. of

No. of No. of No. of

No. of

No. of

Men

marks on the

Women State of Health

probably probably probably probably probably probably curable curable curable incurable curable incurable under under of the Patients, Men. Women. Men. Men. Women. Women. Restraint. Restraint. and condition of the House.

In cases of restraint, the approbation or disapprobation of the physician, surgeon, or apothecary to be certified.

(Signed)

Physician, Surgeon, or Apothecary. To be inspected by the commissioners or visitors at their visitation, and signed

accordingly.

SCHEDULE (K.)

FORM OF PERMISSION for regulating Medical Attendance.

WHEREAS by an act of parliament made and passed in the second and third year of the reign of his present Majesty, intituled "An Act for regulating for Three Years, and from thence until the end of the then next Session of Parliament, the Care and Treatment of Insane Persons in England," it is amongst other things provided and enacted, that when any house licensed for the reception of insane persons shall be licensed to receive less than eleven insane persons, then it shall and may be lawful for a majority of the said commissioners, at any meeting under this act, or the said visitors, if they shall so think fit, to direct and permit that such house shall be visited by the physician, surgeon, or apothecary once at the least in every four weeks, instead of twice in every week, as required by the said act: And whereas on the day of the metropolitan commissioners appointed under the said act [or the justices] duly granted a licence for the space calendar months to for a house situate for the re

of

at

ception of

in the county of insane persons: And whereas the said hath applied to the said commissioners [or visitors] that they will be pleased to direct and permit the said house to be visited once in every four weeks instead of twice in every week: Now know ye, That

Witness

missioners [or visitors] shall think fit.
day of
be subject to such revocation or alteration as the said metropolitan com-
always, and it is hereby expressly declared, that this permission shall
stead of twice in every week, as required by the said act; provided
physician, surgeon, or apothecary once at the least in four weeks, in-
hands and seals direct and permit that the house so licensed to the said
we the undersigned commissioners [or visitors], having thought fit to
one thousand eight hundred
accede to the above request, do by this instrument in writing under our 2
Witness our hands and seals,
as aforesaid shall be visited by a

and

this

& 3 W. 4,

c. 107.

No. IV.

SCHEDULE (M.)

FORM of BOOK of ENTRY of Patients to be kept in the licensed Houses, and of REGISTER to be
kept by the Clerk of the Metropolitan Commissioners and Visitors, and of ANNUAL REPORT to
be made by Public Hospitals and Charitable Institutions.

- In the Book of Entry of Patients to be kept in a licensed House, the Name, Occupation, and Place of Abode of the Person by whom such Patient shall be brought must be entered; and in the Register to be kept by the Clerk of the Commissioners or Clerk of the Peace, the Name of the Proprietor or Resident Superintendant, and of the licensed House in which the Patient is confined, must be added.