[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.
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
Director of the Clinic/Centre/Laboratory
Date Name, Address and Registration number of