53 Vict. c. 5.--Sched. 2, Form 3. ORDER FOR RECEPTION OF A PRIVATE PATIENT, TO BE MADE BY A JUSTICE APPOINTED UNDER THE LUNACY ACT, 1890, JUDGE OF COUNTY COURTS, OR STIPENDIARY MAGISTRATE I, the undersigned _______________________________________________ being (_a_) _________________________________________________ __________________________________________________________________ upon the petition of _____________________________________________ of (_b_) ____________________________________________________ in the Matter of _________________________________________________ a person of unsound mind, accompanied by the Medical Certificates of _______________________________________________________________ and ______________________________________________________________ hereto annexed, and upon the undertaking of the said (_d_) __________________________________________________________________ to visit the said ________________________________________________ personally or by some one specially appointed by the said (_d_) __________________________________________________________________ once at least in every six months while under care and treatment under this Order, hereby authorise you to receive the said _____________________________________________________________ as a patient into your Licensed House (_e_). =And= I declare that I have [_or_ have not] personally seen the said ____________________________________________________ before making this Order. =Dated= this __________________ day of ________________ 19___ =Signed= (_a_) _________________________ _A Justice for _________________________________ appointed under the above-mentioned Act [or the Judge of the County Court of_____________________ or a Stipendiary Magistrate_]. =Urgency Orders.=--Where it is urgent that an alleged lunatic (not a pauper) must be put under restraint as soon as possible, he may be received upon an _urgency order_, without petitioning a Judicial Authority, accompanied by a _statement of particulars_ and _one medical certificate_. The order should be made by the husband, wife, or a relative of the alleged lunatic; if this be not possible, the reasons must be stated. It may be signed before or after the medical certificate, and before or after a petition order has been made. If before, it must be noted in the petition; if after, a copy must accompany the petition. No person may sign an urgency order if under twenty-one years of age, and must have seen the alleged lunatic within two days before the date of the order.