(a) A Justice for —, specially appointed under the Lunacy Act, 1890, or the Judge of the County Court of —, or the Stipendiary Magistrate for—
(b) Address and occupation.
(d) Name of petitioner.
53 Vict. c. 5.—Sched. 2, Form 3.
ORDER FOR RECEPTION OF A PRIVATE PATIENT, TO BE MADE
BY A JUSTICE APPOINTED UNDER THE LUNACY ACT, 1890,
JUDGE OF COUNTY COURTS, OR STIPENDIARY MAGISTRATE
I, the undersigned _______________________________________________
being (a) _________________________________________________
__________________________________________________________________
upon the petition of _____________________________________________
of (b) ____________________________________________________
in the Matter of _________________________________________________
a person of unsound mind, accompanied by the Medical Certificates
of _______________________________________________________________
and ______________________________________________________________
hereto annexed, and upon the undertaking of the said (d)
__________________________________________________________________
to visit the said ________________________________________________
personally or by some one specially appointed by the said (d)
__________________________________________________________________
once at least in every six months while under care and treatment
under this Order, hereby authorise you to receive the
said _____________________________________________________________
as a patient into your Licensed House (e).
And I declare that I have [or have not] personally
seen the said ____________________________________________________
before making this Order.
Dated this __________________ day of ________________ 19___
Signed (a) _________________________