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MTP Consent Form-C

The document contains forms for providing consent for medical termination of pregnancy according to the Medical Termination of Pregnancy Act of 1971 and Rules of 2003 in India. Form C is for a woman's consent and includes fields for her name, age, address and signature. Form C also contains a section for a guardian's consent if the woman is a minor or mentally ill. Form II appears to be a reporting form that collects statistics related to terminations including duration of pregnancy, religion, use of contraception, and reasons for termination.

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NIRMAL MEDICAL
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2K views2 pages

MTP Consent Form-C

The document contains forms for providing consent for medical termination of pregnancy according to the Medical Termination of Pregnancy Act of 1971 and Rules of 2003 in India. Form C is for a woman's consent and includes fields for her name, age, address and signature. Form C also contains a section for a guardian's consent if the woman is a minor or mentally ill. Form II appears to be a reporting form that collects statistics related to terminations including duration of pregnancy, religion, use of contraception, and reasons for termination.

Uploaded by

NIRMAL MEDICAL
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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MEDICAL TERMINATION OF PREGNANCY

(Act 1971 & RULES 2003)


FORM-C
[See Rule 9]

I ________________________ Wife / Daughter of _________________________

Aged about _______ years of ( here state permanent address) ___________________

_________________________________________________________ at present residing

at _________________________________________________________ do here by give

my consent to the termination of my pregnancy at (State the Name of place where

the pregnancy is to be terminated)____________________________________________

__________________________________________________________________________.

Signature

Place :

Date :

(To be filled by guardian where the woman is mentally ill person or minor)

I ________________________ Son /Wife / Daughter of ____________________

Aged about _______ years of ( permanent address) ____________________________

_________________________________________________________ at present residing

at _________________________________________________________ do here by give

my consent to the termination of the my ward _________________________________

who is minor / launtic at (place of termination of my

pregnancy)________________________________________________________________.

Signature

Place :

Date :
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) Sterilization.
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 seal and date

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