In the District Court
held at [place]
In the matter of the Health Act 1956
In the matter of an application for
the committal of [name] to a hospital or institution.
Between [name] of [specify],
Medical Officer of Health,
[name], of [address], [occupation],
Take notice that the above-named applicant will apply to the District Court at [place] on [to be filled in by the Registrar] [date] at [time], for an order that the above-named respondent be committed to a hospital or institution under the control of the [specify] district health board, on the grounds that the respondent is an aged (or infirm or incurable or a destitute) person within the meaning of section 126 of the Health Act 1956, and is living or habitually lives in insanitary conditions (or without proper care or attention).
To the Registrar of the District Court at [place]
To the above-named [name of respondent].
This notice of application is filed by [name] whose address for service is at [specify address].
If in doubt, consult a solicitor or the Registrar immediately.
Schedule form 1: amended, on 1 January 2001, by section 111(2) of the New Zealand Public Health and Disability Act 2000 (2000 No 91).
Schedule form 1: amended, on 1 April 1980, pursuant to section 18(2) of the District Courts Amendment Act 1979 (1979 No 125).
(General title as in form 1)
It is ordered that [name of respondent] be committed to the [name of hospital or institution] to be detained there until he is discharged on the certificate of the Medical Officer of Health.
Dated at: [place, date]