§ I, C.D., having called to my assistance E.F., of, a duly qualified medical practitioner, and, having personally examined A.B. [describing him], hereinafter called the patient, and being satisfied that he is a pauper in receipt of relief [or in such circumstances as to require relief for his proper care and maintenance], and that he is a lunatic [or an idiot, or a person of unsound mind], and a proper person to be taken charge of and detained under care and treatment, [or that he is a lunatic and was wandering at large, and is a proper person to be taken charge of and detained under care and treatment], hereby direct you to receive the said patient into your asylum [or hospital, or house.] Subjoined is a statement of particulars respecting the said patient.
§ (Signed) C.D.
§ A Justice of the Peace for Dated the day of 18.
§ To the superintendent of the* asylum for the county [or borough] of [or the lunatic hospital of, or E.F., proprietor of the licensed house of [describing the asylum, hospital, or house.]
§ Note.—Where the Order directs the lunatic to be received into any asylum other than an asylum of the county or borough in which the parish from which the lunatic is sent is situate, or in a registered hospital or licensed house, it shall state that the justice making the order is satisfied that there is no asylum of that county or borough, or that there is a deficiency of room in that asylum or [as the case may be] the special circumstances by reason whereof the lunatic cannot conveniently be taken to an asylum for the first-mentioned county or borough.
§ [*]If there is more than one asylum for the county or borough, the order may be addressed to the superintendent of "an" asylum of the county or borough of without specifying which.
§ Amendments made: In Form 2, leave out "there is no asylum of that county or borough or that"; in Form 2, leave out "that" ["that asylum"], and after "asylum" insert "of the county or borough if there is such an asylum"; leave out "an" and insert "that"; leave out "for the first-mentioned county or borough."—(Lord Chancellor.)