8 & 9 V., c. 126. Amending the Laws for the Erection and Regulation of

8 & 9 V., c. 126. Amending the Laws for the Erection and Regulation of Lunatic Asylums.

SCHEDULE (E.) No. 1.

ORDER for the RECEPTION of a PAUPER PATIENT.

I, C. D. [in the case of a justice of the peace, or in the case of a clergyman and relieving officer, &c., we], the undersigned, having called to my [or our] assistance a physician [or surgeon or apothecary, as the case may be], and having personally examined A. B., a pauper, and I, C. D. [or we, in the case of a clergyman and relieving officer, &c.,] being satisfied that the said A. B. is a lunatic [or an insane person, or an idiot, or a person of unsound or imbecile mind], and a proper person to be confined, I [or we, as the case may be,] hereby direct you to receive the said A. B. as a patient into your asylum, hospital, or house. Subjoined is a statement respecting the said A. B.

(Signed)

(C. D.)

A justice of the peace for the city or borough of, [or an or the officiating clergyman of the parish of—].

Married, single, or widowed.

Condition of life, and previous occupation (if any).

The religious persuasion, as far as known.

Previous place of abode.

Length of time insane.

Whether first attack.

Age (if known) on first attack.

Whether subject to epilepsy.

Whether suicidal or dangerous to others.

Previous places of confinement (if any).

Dated the

I certify that to the best of my knowledge the above particulars are correctly

stated.

(Signed)

[To be signed by the relieving officer or overseer.]

day of one thousand eight hundred

To, superintendent of the asylum for the county of -, [or the lunatic hospital of —, or proprietor of the licensed house of -]

[describing the asylum, hospital, or house.]

FORM of MEDICAL CERTIFICATE in the Case of PAUPER PATIENTS.

I, -, being a fellow [or licentiate] of the Royal College of Physicians in London, [or a graduate in medicine of the university of -, &c., or a member of the Royal College of Surgeons in London, or an apothecary duly authorized to practise by the Apothecaries' Company in London,] hereby certify that I have this day personally examined A. B., the person named in the accompanying Statement and Order, and that the said A. B. is a lunatic [or an insane person, or an idiot, or a person of unsound or imbecile mind], and a proper person to be confined.

(Signed)

Name.
Place of Abode.

day of, one thousand eight hundred and

-.

In the case of a lunatic not chargeable, to be signed by two justices.

8 & 9 V., c. 126. Amending the Laws for the Erection and Regulation of Lunatic Asylums.

SCHEDULE (E.) No. 2.

ORDER for the RECEPTION of a PRIVATE PATIENT.

I, the undersigned, hereby request you to receive A. B., a lunatic, [or an insane person, or an idiot, or a person of unsound or imbecile mind,] as a patient into your asylum. Subjoined is a statement respecting the said A. B.

(Signed)

Name.

Occupation (if any).

Place of abode.

Degree of relationship (if any), or other circumstance of connexion with the patient.

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.

Duration of existing attack.

Whether first attack.

Age (if known) on first attack.

Whether subject to epilepsy.

Whether suicidal or dangerous to others.

Previous places of confinement (if any).

Whether found lunatic by inquisition, and date of commission.

Special circumstances (if any) preventing the patient being examined, before admission, separately, by two medical practitioners.

Special circumstances (if any) preventing the insertion of any of the above particulars. (Signed)

Dated this - day of, one thousand eight hundred and То -, superintendent of the asylum for the county of [describing the asylum.]

Name.

FORM of MEDICAL CERTIFICATE in the Case of a PRIvate Patient.

I,-, being a fellow [or licentiate] of the Royal College of Physicians in London, [or a graduate in medicine of the university of -, &c., or a member of the Royal College of Surgeons in London, or an apothecary duly authorized to practise by the Apothecaries' Company in London,] hereby certify that, by the direction of -, justice of the peace in and for the, I have this day separately from any other medical practitioner [visited, if applicable, and] personally examined A. B., the person named in the accompanying Statement and Order, and that the said A. B. is a lunatic [or an insane person, or an idiot, or a person of an unsound or imbecile mind], and a proper person to be confined. Subjoined is a statement with respect to the mental and bodily condition of the abovenamed patient.

(Signed)

Name.
Place of abode.

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 medical certificates [or certificate] on which he was received. Subjoined is a statement with respect to the mental and bodily condition of the above-named patient.

I have this day 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]

8 & 9 V., c. 126. Amending the Laws for the Erection and Regulation of Lunatic Asylums.

on the

day of

SCHEDULE (E.) No. 4.

FORM of NOTICE of DISCHARGE or DEATH.

I hereby give you notice, that, private [or à pauper] patient, admitted into this asylum -, was discharged therefrom recovered [or relieved, or not improved, by the authority of — or died therein in the presence of ], on the

(Signed)

day of -.

Dated the day of, one thousand eight hundred and
In case of death add, "I certify that the apparent cause of death of the said
ascertained by post mortem examination (if so),] was

Medical Officer of the Asylum.

(Signed)

SCHEDULE (F.)

QUARTERLY LIST of LUNATIC PAUPERS within the Union of - [or the Parish of -] in the County [or Borough] of not in Asylums, registered Hospitals, or licensed Houses.

I declare that I have personally examined the several persons whose names are specified in this list, on the days set opposite to their names, and that they are all [or all, except A. B., C. D., and E. F.] properly taken care of, and fit to be at large, and that these are the only pauper lunatics, to the best of my knowledge, of the union [or parish] of who are not in an asylum or hospital or house duly licensed for lunatics.

(Signed)
day of

* In the case of an Asylum receiving both private and pauper Patients, a separate Register in the above Form to be kept for each Class.

1848:
Dec. 2 1

1853:

June 8

Relieved.

Not improved.

Died.

Observations.

8 & 9 V., c. 126. Amending the Laws for the Erection and Regulation of

Lunatic Asylums.