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).
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
Name, Address and Registration number
of Genetic Clinic