53 Vict. c. 5, s. 31.
When neither Certificate is signed by the
Usual Medical Attendant.
(a) Name
of
Patient.
I, the undersigned, hereby state that it is not practicable to
obtain a Certificate from the usual Medical attendant of (a)
__________________________________________________________________
for the following reason, viz.:—
(b) To be
signed
by the
petitioner.
(Signed) (b)______________________________
_______________ 19____________
Form 2.