Whereas I have reason to believe that you may be suffering from venereal disease, namely [specify] in a communicable form:
Now therefore, pursuant to the powers conferred on me by the Venereal Diseases Regulations 1982, I do require you—
to submit yourself forthwith to a medical practitioner or the medical officer of any venereal diseases clinic for examination; and
if the venereal disease specified above is syphilis, and the medical practitioner so requires, to submit yourself to him for a further examination on a date or within a period to be fixed by him; and
to forward to me, as soon as practicable after each such examination, a medical certificate in the enclosed form* as to the state of your health in relation to venereal disease.
(Note: For the purposes of this notice a medical certificate may be obtained free of charge from the person in charge of any venereal diseases clinic controlled by a district health board or other organisation funded under the New Zealand Public Health and Disability Act 2000 to provide services of that kind.)
You are hereby informed that if you fail to produce a medical certificate as herein required you may be committed to a hospital or other suitable place, and may be detained there for examination and treatment.
Dated at: [place, date]
Signature of Medical Officer of Health:
|*This document shall be in form 5.|
Schedule form 4: amended, on 18 September 2004, by section 175(3) of the Health Practitioners Competence Assurance Act 2003 (2003 No 48).
Schedule form 4: amended, on 1 January 2001, by section 111(2) of the New Zealand Public Health and Disability Act 2000 (2000 No 91).
Schedule form 4: amended, on 1 July 1993, by regulation 5(1) of the Venereal Diseases Regulations 1982, Amendment No 2 (SR 1993/162).
Schedule form 4: amended, on 1 July 1993, by regulation 5(2) of the Venereal Diseases Regulations 1982, Amendment No 2 (SR 1993/162).