FORM G

[See rule 10]

FORM OF CONSENT

        1...........................................................................................................................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 preseribed in the pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, (57 of 1994).

        Date                                                                                                                                                     Signature

        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.

        Date                                                                            Name, Signature and / Registration number

                                                                                                                                         of Gynaecologist

                                                                    Name, Address and Registration number of Genetic Clinic.