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Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Rules, 1996

FORM E - NAME, ADDRESS AND REGISTRATION No. OF GENETIC LABORATORY RECORD TO BE MAINTAINED BY THE GENETIC LABORATORY

[See Rule 9(3)]

 1. Patient’s name

2. Age

3. Husband’s/Father’s name

4. Full address with Tel. No., if any

5. Referred by/sample sent by (full name and address of Genetic Clinic) (Referral note to be preserved carefully with case papers)

6. Type of sample: Maternal blood/Chorionic villus sample/amniotic fluid/Foetal blood or other foetal tissue (specify)

7. Specify indication for pre-natal diagnosis

A. Previous child/children with

      (i) Chromosomal disorders

     (ii) Metabolic disorders

     (iii) Malformation(s)

     (iv) Mental retardation

     (v) Hereditary haemolytic anaemia

     (vi) Sex linked disorder

     (vii) Any other (specify)

B.Advanced maternal age (-35 years)

C.Mother/father/sibling has genetic disease (specify)

D.Other (specify)

8.Laboratory tests carried out (give details)

             (viii)   Chromosomal studies

             (ix)     Biochemical studies

             (x)      Molecular studies

9.Result of pre-natal diagnosis

            If abnormal give details.                          Normal/Abnormal

10. Date(s) on which tests carried out.

            The results of the Pre-natal diagnostic tests were conveyed to ………………… on …………………….

                                                                     Name, Signature and Registration No. of the Medical Geneticist

Date:

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