(Section 38 (2) (B))

                            Visitor's Visit Request Form

I, Mr/Mrs/Miss …………………………………….wish to visit

Mr/Mrs/Miss …………………………...................who is a patient

of this …………………………………………Psychiatric Hospital

health care facility.

It has been amply explained to me by the hospital authorities that the said patient is violent/ aggressive/ dangerous and that my entering the room or premises where the patient is being kept is at my own risk. I have agreed to take the risk to visit the patient in the room or premises and the facility is absolved from all responsibilities in case of any mishap.

……………………………………………….

Signature of Visitor

Ward Nurse in charge ............................................................................................

Date: