ANNEXURE

FORM MHCA 35

DEPARTMENT OF HEALTH

APPLICATION BY STATE  PATIENT TO JUDGE IN CHAMBERS FOR AMENDMENT TO ANY CONDITION APPLICABLE TO DISCHARGE

REQUESTING UNCONDITIONAL DISCHARGE

(Section 48(6) and (7) of the Act)

Surname of state patient...............................................................................................

First name(s) of state patient .........................................................................................

File No. (if known) .........................................................................................................

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

Residential Address: ...................................................................................................

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

Date of last request for amendment /revocation of conditional discharge :  ..................

(may not be withing six months of current application)

I hereby request that the following term(s), condition(s) of my discharge be amended.

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Reasons for amending condition / requesting unconditional discharge:

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

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

                    (State patient)

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

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

Decision by Judge in Chambers:

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

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

                    (Judge in Chambers

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

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

(Copy to state patient, head of health established, head of the national department, registrar of the High Court and curator ad litem)