Agreement to be signed by persons who are suffering with a venereal disease and are to be released from detention or quarantine, before being cured, or by persons who voluntary submit themselves for treatment to the health clinics as provided by law. State of West Virginia,
County (or City) of ________________
Witnesseth, That I, _________________, residing at _______________, in the county of __________, State of West Virginia, do hereby acknowledge the fact that I am at this time infected with a venereal disease, to wit: with _____________ and that I agree to place myself under the care of ____________________ within _____________ hours hereafter, and that I will remain under treatment of said physician or clinic until released by the health officer of ______________________, or until my case is transferred with the approval of said health officer to another regularly licensed physician or approved clinic; and that I further agree to report to the health officer above, within four days after beginning treatment from the above physician or clinic, of the medical treatment applied in my case, and that I will report thereafter as often as may be required of me by the health officer; and that I further agree to take all the precautions recommended by the health officer to prevent the spread of the above disease to other persons, and to this end that I will perform no act that might expose other persons to the above disease; and that I further agree, until finally released by the health officer, to notify him of any change in my address, and to obtain his consent before moving my abode outside his jurisdiction.
Witness my hand, this the _____________ day of _______________, 19__.
(Signature of Patient)
Approved this the _____ day of __________________, 19__. _________________________________
(Local Health Officer)