The urgency order remains in force seven days from its date, during which period the procedure for a “Judicial Order on Petition” is carried out. If the petition has been presented and the order is for some reason or other deferred, then the urgency order remains in force. The medical examination for certification must have been made not more than two days before reception, and reasons must be given why “it is expedient” that the alleged lunatic should be put under control “forthwith.” [Sidenote: (_a_) House, _or_ hospital, _or_ asylum, _or_ as a single patient. (_b_) _Name of Patient._ (_c_) Lunatic, _or_ an idiot, _or_ a person of unsound mind. (_d_) _Some day within two days before the date of the order._ (_e_) Husband, wife, father, father-in-law, mother, mother-in-law, son, son-in-law, daughter, daughter-in-law, brother, brother-in-law, sister, sister-in-law, partner, or assistant. (_If not the husband or wife, or a relative of the patient, the person signing to state as briefly as possible_--1. _Why the order is not signed by the husband or wife, or a relative of the patient._ 2. _His or her connection with the patient, and the circumstances under which he or she signs._) (_f_) Superintendent of ____ the ____ asylum, ____ hospital _or_ resident licensee of the ____ house (_describing the asylum, hospital, or house by situation and name_.) Lunacy, Nos. 4 & 2. (33 Vict. c. 5, s. 11.)] 53 Vict. c. 5.--Sched. 2. FORM OF URGENCY ORDER FOR THE RECEPTION OF A PRIVATE PATIENT, WITH MEDICAL CERTIFICATE AND STATEMENT ACCOMPANYING URGENCY ORDER Forms 4, 2, 8 and 9. I, the undersigned, being a Person Twenty-one years of age, hereby authorise you to receive as a Patient into your (_a_) House (_b_) _________________________________________________ __________________________________________________________________ as a (_c_) __________________________________whom I last saw at ____________________________________________________________________ on the (_d_) __________________ day of_______________ 19____ I am not related to or connected with the Person signing the Certificate which accompanies this Order in any of the ways mentioned in the Margin. (_e_) Subjoined (_or_ annexed) hereto is a Statement of Particulars relating to the said __________ (=Signed=) _____________________________________ _Name and Christian Name_ } _______________________________ _at Length_ } _______________________________ _Rank, Profession, or Occupation_ } _______________________ _(if any)_ } _______________________ _Full Postal Address_ _____________________________________ _How related to or connected_ } ___________________________ _with the patient_ } ___________________________