No entry shall be made in any case-sheet, operation theatre register, follow-up card or any other document or register other than the Admission Register maintained at any hospital or approved place indicating therein the name of the pregnant woman and reference to the pregnant woman shall be made therein by the serial number assigned to the woman in the Admission Register.
Form I
[See Regulation 3]
I,
(Name and qualifications of the Registered Medical Practitioner in block letters)
(Full address of the Registered Medical Practitioner)
I,
(Name and qualifications of the Registered Medical Practitioner in block letters)
(Full address of the Registered Medical Practitioner) hereby certify that *I/We, am/are of opinion, formed in good faith, that it is necessary to terminate the pregnancy of
(Full name of pregnant woman in block letters) resident of
(Full address of pregnant woman in block letters)
for the reasons given below**.
* I/We, hereby give intimation that *I/We, terminated the pregnancy of the woman referred to above who bears the serial no . in the Admission Register of the hospital/approved place.
Place :Signature of the Registered Medical Practitioner/Practitioners
Date :
Strike out whichever is not applicable,
**of the reasons specified items (i) to (v) write the one which is appropriate:
(i) in order to save the life of the pregnant woman,
(ii) in order to prevent grave injury to the physical and mental health of the pregnant woman,
(iii) in view of the substantial risk that if the child was born, it would suffer from such physical or mental abnormalities as to be seriously handicapped,
(iv) as the pregnancy is alleged by pregnant woman to have been caused by rape,
(v) as the pregnancy has occurred as result of failure of any contraceptive device or methods used by married woman or her husband for the purpose of limiting the number of children.
Note: Account may be taken of the pregnant woman's actual or reasonably foreseeable environment in determining whether the continuance of her pregnancy would involve a grave injury to her physical or mental health.
Place:
Date : Signature of the Registered Medical Practitioner/Practitioners
Form II
[See Regulation 4(5)]
1. Name of the State
2. Name of the Hospital/approved place
3. Duration of pregnancy (give total No. only)
(a) Up to 12 weeks.
(b) Between 12-20 weeks
4. Religion of woman
(a) Hindu
(b) Muslim
(c) Christian
(d) Others
(e) Total
5. Termination with acceptance of contraception
(a) Sterlisation
(b) I.U.D.
6. Reasons for termination:
(give total number under each sub-head)
(a) Danger to life of the pregnant woman.
(b) Grave injury to the physical health of the pregnant woman.
(c) Grave injury to the mental health of the pregnant woman.
(d) Pregnancy caused by rape.
(e) Substantial risk that if the child was born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.
(f) Failure of any contraceptive device or method.
Signature of the Officer Incharge with Date
Form III
[See Regulation 5]
Admission Register
(To be destroyed on the expiry of five years from the date of the last entry in the Register)
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| S. No. |
Date of Admission |
Name of the Patient |
Wife/Daughter of |
Age |
Religion |
Address |
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9 |
10 |
11 |
12 |
13 |
14 |
| Dura-tion of pregnancy |
Reasons on which pregnancy is terminated |
Date of termination of pregnancy |
Date of discharge of patient |
Result and Remarks |
Name of Registered Medical Practitioner(s) by whom the opinion is formed |
Name of Registered Medical Practitioner(s) by whom pregnancy is terminated |
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