Rank, profession, or occupation (if any) _________________________ How related to or otherwise connected } __________________________ with the patient } __________________________ [Sidenote: (_a_) _Insert residence of patient._ (_b_) County, city, _or_ borough, _as the case may be._ (_c_) _Insert profession or occupation, if any._ (_d_) _Insert the place of examination, giving the name of the street, with number or name of house, or should there be no number, the Christian and surname of occupier._ (_e_) County, city, _or_ borough, _as the case may be._ (_f_) _A lunatic_, an idiot, _or_ a person of unsound mind. (_g_) _If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them in a separate paragraph._ (_h_) _The names and Christian names (if known) of informants to be given, with their addresses and descriptions._ Lunacy, Nos. 8 & 9. (53 Vict. c. 5, ss. 11, 28, 29, 32 and 33.)] 53 Vict. c. 5.--Sched. 2, Form 8. CERTIFICATE OF MEDICAL PRACTITIONER In the Matter of _________________________________________________ of (_a_) ____________________________________________________ in the (_b_)________________________ of _____________________ (_c_) _______________________________________________________ an alleged lunatic. I, the undersigned _______________________________________________ do hereby certify as follows:-- 1. I am a person registered under the Medical Act, 1858, and I am in the actual practice of the medical profession. 2. On the ________________ day of ___________________ 19 ______ at (_d_) ______________________________________________ in the (_e_) ________________ of ______________________ I personally examined the said _____________________________ and came to the conclusion that ____ he is (_f_)_______ and a proper person to be taken charge of and detained under care and treatment. 3. I formed this conclusion on the following grounds, viz.:-- (_a_) Facts indicating Insanity observed by myself at the time of examination (_g_), viz.:-- __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (_b_) Facts communicated by others (_h_), viz:-- __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ [Sidenote: (_i_) _If an urgency certificate is required, it must be added here.--Form No. 9._