FORM 10.

[Name of Asylum, Hospital, or House.]
MEDICAL STATEMENT.

I have this day [some day not less than two clear days nor more than seven clear days after the admission of the patient] seen and examined admitted into this asylum [or hospital or house] on the

day of

and hereby certify that with respect to mental state he [or she] [describing it] and with respect to bodily health and condition he [or she] [describing it].

NOTICE OF TRANSFER FROM THE CRIMINAL TO THE PAUPER CLASS.

Date of reception order, the

I hereby give you notice that

day of

who was received into this

asylum (or hospital) as a criminal lunatic on the

was on the transferred to the pauper class, and I herewith transmit a copy of the justice's order on which he is detained. Subjoined is a statement with respect to the mental and bodily condition of the patient.

Dated the

(Signed)

To the Commissioners in Lunacy.

STATEMENT.

I have this day [some day not less than two clear days, nor more than seven clear days, after the patient has ceased to be a criminal] seen and examined the patient mentioned in the above notice, and hereby certify that with respect to mental state he [or she] [describing it] and with respect to bodily health and condition he [or she] [describing it].

(To be sent at the expiration of one calendar month after reception.) I have this day seen and examined received here on the

day of

and report that with respect to mental condition

Medical Officer, or Medical Attendant.

To the Commissioners in Lunacy.

FORM 14.

[Name of Asylum, Hospital, or House.]

NOTICE OF REMOVAL.

day of

a private [or pauper or

was, on the

Date of reception order, the

I hereby give you notice that

day of

removed to

criminal] patient received into this asylum [or hospital or licensed house or house] on the day of

relieved [or not improved] by the authority of

(Signed)

Clerk, or Superintendent, or Resident Licensee, or the person having charge of the said lunatic as a single patient.

Dated the

day of

To the Commissioners in Lunacy

[or as the case may be].

FORM 15.

[Name of Asylum, Hospital, or House.]

NOTICE OF DISCHARGE.

Date of reception order, the

I hereby give you notice that

day of

a private

[or pauper, or criminal] patient, received into this asylum [or hospital [or licensed house or house] on the

day of

was discharged therefrom recovered [or relieved or not improved] on the by the authority of

Dated the

day of

day of

To the Commissioners in Lunacy [or as the case may be.]

1

(Signed)

Clerk, or Superintendent, or Resident Licensee, or the person having charge of the said lunatic as a single patient.

FORM 16.

[Name of Asylum, Hospital, or House.]

NOTICE OF ESCAPE.

I hereby give you notice that

day of

private [or pauper or

escaped therefrom

criminal] patient received into this asylum [or hospital or licensed house or house] on the

The state of mind of the patient at the time of his escape was as follows [describe it.]

The circumstances and manner of the escape were as follows [state them.]

a private [or pauper or criminal] patient who was received into this asylum [or hospital or

[Name of Asylum, Hospital, or House.]

NOTICE OF TRANSFER FROM PRIVATE TO PAUPER CLASS OR VICE VERSA.

I hereby give you notice that

admitted into this

asylum [hospital or house] as a private [or pauper] patient on the

day of

was on the

transferred to the pauper [or private] class.

day of

[Name of Asylum, Hospital, or House.]

SPECIAL REPORTS and CERTIFICATES as to Patients admitted under Orders dated Three Months or more prior to May 1, 1890.

(LUNACY ACT, 1890, SECTION 38; LUNACY ACT, 1890, SECTION 7.)

Note.-Male and female patients must be returned in separate lists. The names must be in alphabetical order of the initial letters, and those of each initial in order of date of admission.

Date of Admission.

Dates of
Reception.
Orders.

Names of Patients.

Report as to Mental
Condition.

Report as to Bodily
Condition.

I certify that all the patients named on this sheet are still of unsound mind, and proper persons to be detained under care and treatment.

Dated the

day of

To the Commissioners in Lunacy.

(Signed)

Medical Officer.

FORM 20.

(Private or Pauper.)

No.*

[Name of Asylum, Hospital, or House.]

SPECIAL REPORT AND CERTIFICATE.

(LUNACY ACT, 1890, SECTION 38; LUNACY ACT, 1891, SECTION 7.)

Name of patient

Date of admission

Date of reception order

I have this day seen and examined the above-named patient, and beg to report that with regard to mental condition, he [or she] is

and with regard to bodily condition, he [or she] is

and I hereby certify that he [or she is still of unsound mind, and a proper person to be detained under care and treatment.

*(For use by Commissioners in Lunacy only.)

patient received into this asylum [or hospital or house] on the

a private [or pauper]

day

day of

Clerk of Asylum or Medical Officer
of Hospital, or House, or Medical
Attendant of the patient.

To the Commissioners in Lunacy

[or as the case may be].

Name

STATEMENT RESPECTING THE ABOVE-NAMED PATIENT.

Sex and age

Married, single, or widowed

Profession or occupation

Place of abode immediately before

being placed under care and treatment (if known)

Apparent cause of death

Whether or not ascertained by postmortem examination

Time and any unusual circumstances attending the death; also a description of any injuries known to exist at time of death or found subsequently on body of deceased.