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173
SCHEDULE.
Form of Notification.
Public Health (Tuberculosis in Hospitals) Regulations, 1911.
To the Medical Officer of Health for the------------------------------------
of ;
I hereby give you Notice that, in my opinion,
who is now an
in-patient
out-patient
at the Hospital
and in relation to whom particulars are appended, is suffering from Pulmonary
Tuberculosis.
Residence* prior to attendance
at or admission to the
above-named Hospital.-----------------------------------------------------------------------------
Age__
Sex
Dated this day of . 19 .
Signed
Medical Officer in attendance on
the above-named Patient.
* Care should be taken to ascertain accurately the patient's place of residence. 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.
Given under the Seal of Office of the Local Government Board, this Twentysecond
day of March, in the year One thousand nine hundred and
eleven.
©John Burns,
President.