Temporary Treatment Orders (TTO)

exp date isn't null, but text field is

THE MENTAL TREATMENT ACT

(Cap. 34:02)

(Under section 22 0f the Act.)

 

Name of referring hospital…………………………………………………………………...

 

Cap. 34:02          Mental treatment

(subsidiary)        mental treatment: (prescriber form) Rules

Form no.

 

In the matter of ………………………………………………………………………………...………… (Name of the patient)

In the district of……………………………………………………………………………………………………………………………….

I ……………………………………………………………………………………………………………hereby to certify as follows

I on the …………………………………………….……. day of …………………………………………………………………………...

At the ……………………………………...in the district of ……………………………………………………………………………

I personally examined the said ……………………………………………………………………………………………………...

Is of unsound mind and a proper person to be taken in charge and detailed under care.

I formed this conclusion on the following grounds:

Facts and citing insanity observed by myself (here state observation).

 

Other facts, if any indicating insanity communicated to me by other (here information and from when).

 

Name of attending clinician and prescriber no. ……………………………………………………………………………...

Signed…………………………………………………………………. Qualification……………………………………………………

(Here state whether the person giving the certification is a registered or licensed medical practitioner)