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Medical Termination of Pregnancy Regulations, 2003

FORM III - Admission Register 
( See Regulation 5 )


( To be destroyed on the expiry of five years from the dated of the last entry in the Register )

 

 1

2

3

4

5

S.No

Date of Admission

Name of the Patient

Wife/Daughter of

Age

 

 

 

 

 

 

6

7

8

9

10

Religion

Address

Duration of Pregnancy

Reasons on which Pregnancy is terminated

Date of termination of Pregnancy

 

 

 

 

 

 

11

12

13

14

Date of discharge of patient

Result and Remarks

Name of Registered Medical Practitioner (s) by who the opinion is formed

Name of Registered Medical Practitioner (s) by whom Pregnancy is terminated

 

 

 

 

 
 
 
 
 
 
 

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