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
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
(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)
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
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