ANNEXURE

FORM MHCA 24

DEPARTMENT OF HEALTH

TRANSFER OF STATE PATIENTS AND MENTALLY ILL PRISONERS BETWEEN DESIGNATED HEALTH ESTABLISHMENTS

(Sections 43(1) and 54(1) 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 shall be transferred:

From: ......................................................................(name of health establishment)

To: ...........................................................................(name of health establishment)

Reasons to transfer:

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

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

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

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

Print Initials and Surname: .......................................

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

                   (Head of  provincial department)

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

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

Concurrence of Head of Province to where the state patient or mentally ill prisoner is to be transferred must be obtained where inter-provincial transfers are contemplated.

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

                    (Head of provincial department)

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

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

(Copy to be forwarded to official curator ad litem, head of national department and head of health establishment to where state patient or mentally ill prisoner is transferred)