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SCHEDULE FORM 1 MENTAL HEALTH REGULATIONS 1995 (reg. 5(a) ORDER FOR ADMISSION AND DETENTION IN AN APPROVED TREATMENT CENTRE (S. 12(1)) To: The Director,.......................................................... (approved treatment centre) 1. I have at *am/pm on this date__/__/__ (time) __:__ completed my examination of ................................................... (full name in block letters) of ............................................................................. (address in block letters) sex* male / female, date of birth__/__/__ 2. The above person *is/is not already a voluntary patient in the treatment centre. 3. As a result of my examination I am satisfied-
4. The grounds on which I have formed my opinion are as follows (additional reports *are/are not attached):
5. I make an order for-
Name (block letters) Date __/__ /__
Address (block letters) Time *am/pm
Signature (Medical Practitioner)
*Cross out whichever is not applicable.
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