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BOROUGH OF CAMBERWELL
CONFIDENTIAL
No.__________
For Official use only
APPLICATION FOR PRIORITY
REHOUSING ON MEDICAL GROUNDS
Recomm.
Date
PART I
Name of applicant__________
Address__________
PART II To be completed by MEDICAL PRACTITIONER
Name of patient __________ Age __________
This patient suffers from __________
As a result of your visits, what housing features do
you consider adversely affect this condition?
__________________________________________________
__________________________________________________
__________________________________________________
Bearing in mind your knowledge and experience of other
cases requiring rehousing, into which of the following
categories of medical priority should this patient's name be
placed -
1. Most urgent __________
2. Urgent __________
3. Soon __________
4. No priority __________
Date __________ Signed __________
Medical Practitioner
It is regretted that no fee can be paid
for this certificate.
PLEASE RETURN FORM IN THE ENCLOSED STAMPED ADDRESSED
ENVELOPE