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118
FORM C.
Appendix H.
Corporation of London.
PUBLIC HEALTH DEPARTMENT.
PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912.
*FORM OF NOTIFICATION to be used by Medical Officers of
Poor Law Institutions and Sanatoria under Article VII. (a)
for Patients who have been notified before admission.
To the Medical Officer of Health
for the City of London, Guildhall, E.C.
I hereby give you Notice that the persons affected with L uberculosis, of
whom particulars are given below, have been admitted to †—
during the week ending—19—
Name in full.
Age.
Localisation of
Disease.
Place of Residence before Admission.
(Give Address in full.)‡
Dated this—day of—19.
Medical Officer of the above-named Institution.
*Patients who have not been notified before admission are to be notified on Form A.
†Here state the name of the Institution.
‡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. In the case of a Patient transferred to an Institution from
another Institution, the "place of residence before admission" shall mean the place of residence before
the Patient's admission to the first Institution.