- An order of discharge made under section 31 to 34 shall be in the from given in Appendix VI.Appendix (I)(Vide rule5)Application Form For Reception(For Voluntary Boarders)ToThe Visitors,Mental Hospital.Sir,I............hereby request that you will authorise the Superintendent.........Mental Hospital, to receive me into the above mentioned institution as a voluntary boarder under the proviso to sub-section (1) of section 4 of the Indian Lunacy Act IV of 1912.I hereby engage to pay the cost of maintenance in the.........Mental Hospital at rate of Rs.........per day (or I hereby declare that I am destitute and unable to defray the cost of my maintenance).I beg to remain.Sir,Yours faithfullySignature of the Applicant.Address :Date :I hereby certify that I am willing to receive Mr....... for treatment as a voluntary boarder in the.........(Mrs./Miss.......... Mental Hospital; accommodation for him/her is available.Date :Superintendent.Mental Hospital.Approved.Approved.Signature of the visitor (1)..................(2).......................Date :Appendix II[Vide rule 7 (2)]Certificate of fitness for transfer and condition of Health in case of Lunatice sent to asylumStation.Date.Criminal LunaticCertified that the lunatic.............. (name)........... is in sufficiently good health, and in a fit state to travel from..........(name of station) to the............... Mental Hospital ........at.........Sd/- Medical Officer,Medical Practitioner.N.B. - The certificate may be signed by any registered medical practitioner or medical officer.Appendix IIIForm of Medical History Sheet of a Lunatic[Vide Rule 7 (1)]N.B. - The ultimate responsibility for the preparation of this form rests with the committing Officer, who must see that requisite information is supplied by the police and the Medical Officer without undue delay.Questions to be answered upon informationSupplied by the Police alone
