ANNEXURE

FORM MHCA 21

DEPARTMENT OF HEALTH

NOTICE TO TRANSFER OF STATE PATIENT OR MENTALLY ILL PRISONER

(Sections 43 (8) or 54(6) of the Act)

Surname of state patient / mentally ill prisoner  ...................................................................

First name(s) of state patient / mentally ill prisoner .............................................................

Date of birth  ..............................or estimated age ...................

The above state patient or mentally ill prisoner has  been transferred:

From ........................................................................................................................

            (name of health establishment)

To: ...........................................................................................................................

          (name of health establishment)

Reasons for transfer:

...............................................................................................................................

................................................................................................................................

...............................................................................................................................

Date of transfer: .....................................................................................................

Print initials and surname: ....................................................................

Signature: .............................................................................................

(person effecting the transfer)

Date: ....................................

Place: ............................................

[Copy :

In respect of state patient to be sent to official curator ad litem and National Department. In respect of mentally ill prisoner to be sent to the head of the relevant prison, Review Board and national department as well as to the administrator where appointed]