ANNEXURE

FORM MHCA 03

DEPARTMENT OF HEALTH

DISCHARGE REPORT FROM THE MENTAL HEALTH ESTABLISHMENT

(Section 16, 37(6) or 56 of the Act)

Full name of User ...................................................................................

ID Number:   ..........................................................................................

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

Name of health establishment: ................................................................................

Date of admission: ...................................................................................................

Date of discharge: .....................................................................................................

Diagnosis on discharge: .............................................................................................

Planned further care, treatment and rehabilitation:

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

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

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

Compiled by:

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

Designation: ........................................................................................................

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

                     (Head of health establishment)

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

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

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

[Copy to be submitted to the relevant authority in terms of the applicable provision:]