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116
FORM A
Appendix F.
Corporation of London.
PUBLIC HEALTH DEPARTMENT.
PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912.
FORM OF NOTIFICATION UNDER ARTICLE V.
(i.e. of Cases not previously notified.)
To the Medical Officer of Health for the City of London, Guildhall, E.C.
I hereby give you notice that, in my opinion,
in relation to whom particulars are appended, is suffering from Tuberculosis
of the *—
†Place of Residence at date of notification—
†Usual place of Residence (if other than stated above)—
Age—
Sex—
Occupation—
Dated this—day of—19—
Signature of Notifying Practitioner.—
Qualifications.—
Address—
*Here state the localisation of the disease.
†Care should be taken to ascertain accurately the patient's place of residence. Where necessary the name of the
town or village, and of the county in which it is situated, should be stated, as well as the name or number
of the house and the name of the street.