FORM G

[See Rule 10]

FORM OF CONSENT

(For invasive techniques)

             I, ………………………………… wife/daughter of ……………………………. Age ……… years residing at ……………………………………….. hereby state that I have been explained fully the probable side effects and after effects of the pre-natal diagnostic procedures. 

 I wish to undergo the preimplantation/pre-natal diagnostic technique/test/procedures in my own interest to find out the possibility of any abnormality (i.e. disease/deformity/disorder) in the child I am carrying.

I undertake not to terminate the pregnancy if the pre-natal procedure/technique/test conducted show the absence of disease/deformity/disorder.

I understand that the sex of the foetus will not be disclosed to me.

I understand that breach of this undertaking will make me liable to penalty as prescribed in the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 (57 of 1994) and rules framed thereunder.

Date                                           Signature of the pregnant woman.

Place

            I have explained the contents of the above to the patient and her companion (Name …………………………………….. Address ……………………………. Relationship ………………..) in a language she/they understand.

 
Name, Signature and/Registration number of
Gynaecologist/Medical Geneticist/Radiologist/Paediatrician/
Director of the Clinic/Centre/Laboratory

 Date                                                Name, Address and Registration number of 
                                                                                                  Genetic  Clinic/Institute

SEAL