2040

THE NEW ZEALAND GAZETTE.

SCHEDULE.
Form No. 1.
(Confidential.)

NOTIFICATION OF VENEREAL DISEASE.
Under the Social Hygiene Regulations, 1925.

To the Director-General of Health, Wellington.

PURSUANT to the provisions of the Social Hygiene Regulations, 1925, I hereby notify that [Name, address, and occupation], who has been under treatment by me for [Specify disease] since [Insert date], has failed to attend for further treatment, as prescribed by me, and that such default has continued for not less than fourteen days. When last examined by me on the __day of __, 19_, the patient was still suffering from the said disease in a communicable form, and I have no reason to believe that he is receiving treatment from any other qualified person.
Dated at __this____ day of __, 19__.
[Signature.]

Form No. 2.
(Confidential.)

NOTICE REQUIRING PERSON TO FURNISH MEDICAL CERTIFICATE IN RELATION TO VENEREAL DISEASE.

Under the Social Hygiene Regulations, 1925.

To __of __.
WHEREAS it has been represented to me that you are suffering from venereal disease:
Now, therefore, pursuant to the powers conferred on me by the Social Hygiene Regulations, 1925, I do require you, the said ___, of __, forthwith to submit yourself for examination to a registered medical practitioner, and to forward to me, on or before the __day of __, 19__, a medical certificate as to the state of your health in relation to venereal disease in a communicable form.
For the purposes of this notice, a medical certificate may be obtained free of charge from the Medical Superintendent of any public hospital, or from the Medical Officer in charge of any clinic for the treatment of venereal diseases established by the Department of Health or by any public hospital.
You are hereby informed that if you fail to produce a medical certificate as herein required you may be committed to a public hospital or other place of detention, and may there be detained for examination and treatment.
Dated at __this____ day of __, 19__.

Director-General of Health.

Form No. 3.
(Confidential.)

NOTICE REQUIRING PERSON TO SUBMIT TO EXAMINATION BY TWO MEDICAL PRACTITIONERS.

Under the Social Hygiene Regulations, 1925.

To __of __.
WHEREAS by notice under my hand dated the __day of __, 19__, you were required to furnish a medical certificate on or before the day of __, 19__, as to the state of your health in relation to venereal disease: And whereas you have failed to furnish such certificate [or And whereas the certificate by _, dated the __day of __, 19__, does not definitely disclose whether or not you are suffering from any venereal disease in a communicable form]:
Now, therefore, pursuant to the powers conferred on me by the Social Hygiene Regulations, 1925, I do require you, the said _, of __, to attend at [Specify place] at [Specify time] on the __day of __, 19__, there to be examined by two medical practitioners for the purpose of determining whether or not you are suffering from any venereal disease in a communicable form.
If you fail to attend for examination as herein required, or, having attended, if you refuse to submit to examination, you are guilty of an offence against the Social Hygiene Regulations, 1925, and are liable to a fine of £20.
Dated at __this____ day of __, 19__.

Director-General of Health.

Form No. 4.
WARNING.

Under the Social Hygiene Regulations, 1925.

TAKE notice that you are suffering from an infectious venereal disease—namely [Specify disease]. By virtue of the Social Hygiene Act, 1917, and the Social Hygiene Regulations, 1925,—
(a.) You are required to continue to receive medical treatment until cured.
(b.) If at any time you change your medical adviser you should notify your former adviser; otherwise your name, address, occupation, and condition of health are required to be notified to the Director-General of Health. If you continue treatment, no such notice is required to be given.
(c.) Until further notice, you are required to attend for further treatment as follows [Insert directions].
(d.) [In cases where patient is not married.] You are hereby expressly warned against marrying until you have been medically certified as cured.
(e.) If you knowingly infect any other person, or do or suffer any act likely to infect any other person, you are liable to imprisonment for twelve months, together with a fine of £100.

No. 51