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104
C.—Form of Certificate.
The Infectious Disease (Notification) Act, 1889.
st. giles district, middlesex.
To the Medical Officer of Health.
I hereby certify and declare that in my
opinion
an inmate of
is suffering from
Dated the day of 18
(Signed) Name
Address
Medical Practitioner.
N.B.—This Certificate must (under a penalty not exceeding forty shillings)
be sent to the Medical Officer of Health forthwith on the Medical Practitioner
attending on or called in to visit the patient becoming aware that
the patient is suffering from an infectious disease to which the Act applies;
namely, any of the following diseases:—Small-pox, cholera, diphtheria,
membranous croup, erysipelas, the disease known as scarlatina or scarlet
fever, and the fevers known by any of the following names: typhus, typhoid,
enteric, relapsing, continued or puerperal, and also any infectious disease to
which the Act has been applied by the Local Authority in manner provided by
the Act.
D.—Form of Copy of Certificate sent to Metropolitan
Asylums Board in order to obtain Repayment of Expenses.
The Board of Works for the St. Giles District.
Date 18
To the Managers of the
Metropolitan Asylum District
In accordance with Section 10 of the Infectious Disease (Notification)
Act, 1889, I beg to hand you copies of Certificates received by me
this day from Medical Practitioners, relative to cases of disease in this
district.
Your obedient Servant,
Signature
Medical Officer of Health for
ST. GILES DISTRICT BOARD.
Name of
Patient.
Age.
Sex.
Address.
Description
of Disease.
Name of
Medical
Practitioner
who signed
Certificate.
Address.
Date of
Certificate.