5. I am not related to or connected with either of the persons signing the certificates which accompany this petition as (_where the petitioner is a man_) husband, father, father-in-law, son, son-in-law, brother, brother-in-law, partner, or assistant (_or where the petitioner is a woman_) wife, mother, mother-in-law, daughter, daughter-in-law, sister, sister-in-law, partner, or assistant. 6. I undertake to visit the said________________________ __________________________personally, or by some one specially appointed by me, at least once in every six months while under care and treatment under the order to be made on this petition. 7. A statement of particulars relating to the said_____________ ______________________________________accompanies this petition. _If it is the fact, add_: 8. The said_____________________ has been received in the Haydock Lodge Licensed House, Newton-le-Willows, under an Urgency Order dated the____________ _______________________________________________________________ The petitioner therefore prays that an order may be made in accordance with the foregoing statement. =Signed= (_k_)_______________________________________ Date of Presentation of the Petition, this____________ day of___________________ 19_________ [Sidenote: (_a_) Name of Patient. (_b_) To be signed by the petitioner.] 53 Vict. c. 5, s. 31. When neither Certificate is signed by the Usual Medical Attendant. I, the undersigned, hereby state that it is not practicable to obtain a Certificate from the usual Medical attendant of (_a_) __________________________________________________________________ for the following reason, viz.:-- (=Signed=) (_b_)______________________________ _______________ 19____________ Form 2. STATEMENT OF PARTICULARS REFERRED TO IN THE ANNEXED PETITION _If any particulars are not known the fact is to be so stated._ [Where the patient is in the petition or order described as an idiot, omit the particulars marked ►] The following is a Statement of Particulars } __________________ relating to the said } __________________ Name of patient, with Christian name at } __________________ length } __________________ Sex and Age __________________ ► Married, single, or widowed __________________ ► Rank, profession, or previous occupation } __________________ (if any) } __________________ ► Religious persuasion __________________