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

FORM G - FORM OF CONSENT

[See Rule 10]

              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 pre-natal diagnostic procedures in my interest to find out the possibility of any abnormality (i.e. deformity or disorder) in the child I am carrying.

             I undertake not to terminate the pregnancy if the pre-natal procedure and any pre-natal tests conducted show the absence of deformity or disorders. 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).

 
Signature
 
Date                                                                                                   

Place

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

 

                     Name, Signature and/Registration number of Gynaecologist

Date

                         Name, Address and Registration number
                         of Genetic Clinic


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