I certify that it is expedient for the welfare of the said
_______________________ (or for the public safety, as
the case may be) that the said ________________________________
should be forthwith placed under care and treatment.
My reasons for this conclusion are as follows: __________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
(k) Strike out this clause in case of a private patient whose removal is not proposed.
4. The said ___________________________________
appeared to me to be [‡ _____________] in a fit condition
of bodily health to be removed to an asylum, hospital,
or licensed house(k).
(‡) Or not to be.
5. I give this certificate having first read the section of the Act
of Parliament printed below.
Dated this ________________ day of ________________
One thousand nine hundred and ______________
(l) Insert full postal address.
(Signed) _____________________________
of (l) _____________________________
Extract from section 317 of the Lunacy Act, 1890.