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156
form of certificate to be sent to medical officer
of health.
THE INFECTIOUS DISEASE (NOTIFICATION) ACT, 1889.
CERTIFICATE OF MEDICAL PRACTITIONER.
PARISH OF ST GILES, CAMBERWELL.
To the Medical Officer of Health,
I hereby certify and declare, that in my opinion
an inmate of2
is suffering from3
Dated the day of , 18
Signed, Medical Practitioner.
1. Name in full of person suffering from disease.
2. No. or name of the house, and name of the street or road, and parish or place,
where person is resident. In the case of a ship, boat, tent, van, shed, or
other similar structure, the name or description of the dwelling, and the
name of the place where it is situate should be given.
3. Name of disease.
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.