Signed________________________________________
________________ 19________
Note.—This Copy is to be obtained from the Commissioners
in Lunacy by the Petitioner at his own expense.
An Order for Reception of a Lunatic is to be obtained upon a private application by Petition to a Judge of County Courts, or Stipendiary Magistrate, or Metropolitan Police Magistrate, or specially appointed Justice of the Peace. The petition is to be presented, if possible, by the husband or wife, or by a relative (i.e. a lineal ancestor or lineal descendant, or lineal descendant of an ancestor not more remote than great-grandfather or great-grandmother) of the Lunatic, and is to be accompanied by a Statement of Particulars and two Medical Certificates on separate sheets of paper. One of the Medical Certificates accompanying the Petition must, if practicable, be by the usual Medical Attendant of the Lunatic; if not by him, the reason must be stated ([see Form above]). If a previous Petition has at any time been dismissed, the facts relating to its dismissal are to be stated in the fresh Petition ([see Form above]); and the Petitioner must obtain from the Commissioners in Lunacy a Copy of the Statement sent to them of the reasons for its dismissal, and present this copy with his Petition. The Reception Order (which will not remain in force for more than seven days after its date), the Petition, the Statement of Particulars, and the Medical Certificates must be sent to the Superintendent or Proprietor of the Asylum, Hospital, or House where the Patient is to be received.
(a) Insert residence of patient.
(b) County, city, or borough, as the case may be.
(c) Insert profession or occupation, if any.
53 Vict. c. 5.—Sched. 2, Form 8.
CERTIFICATE OF MEDICAL PRACTITIONER
In the Matter of_________________________________________