View report page

Date
Name of Patient
Age
Sex
No. of House and Street
Occupier
Disease
Notice of freedom from
Infection forwarded to
Medical Officer of Health
18
[X]
Borough of Kingston-upon-Thames.
Certificate by a Medical Practitioner
that a Patient suffering from
is now recovered and free from infection.
Name of Patient
Age
Address
Disease
Has the House and
Clothing been disin Yes or No
fected under Medical
Practitioner's directions
Do the House and Yes or No
Clothing require dis-
infection
Dated the day of 18
Signed
Medical Practitioner.
Note.—The Corporation trust that Medical
Practitioners will duly send this Certificate to
the Medical Officer of Health, and so co-operate
in the prevention of the spread of Infectious
Disease.
BOROUGH OF KINGSTON-U PON-THAMES.
Certificate by a Medical Practitioner under the
Kingston-upon-Thames Improvement Act, 1888, when a
person is suffering from:—Smallpox, Cholera, Diphtheria,
Membranous Croup, 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 such other diseases as the
Corporation under the provisions of the above mentioned
Act may from time to time declare to be infectious.
TO THE CORPORATION OF KINGSTON-UPON-THAMES.
Pursuant to the above mentioned Act, I hereby certify and declare
that in my opinion the undermentioned person is suffering from a
disease within the terms of such Act:—
Name in Full of Patient
Age of Patient Sex of Patient
Full Address of House of which Patient is
an Inmate
Name of Occupier or other person in charge
of such House
Nature of Disease
State whether Patient has been or is
intended to be removed and the
tination
Dated this day of 18
Signed
Medical Practitioner,
Note.—This Certificate must (under a penalty of Forty Shillings in
case of neglect) be forthwith delivered by the Medical Attendant of the
infectious patient to the Medical Officer of Health, Clattern House,
Kingston-upon-Thames.