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    Sunscans

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    Rajesh Pradhan
    This document contains a form documenting a prenatal diagnostic test conducted on Sudha Rani. Section A provides patient details like name, age, address, last menstrual period. Section B documents the non-invasive ultrasound procedure conducted, including the doctor's name, indication for the test, date, and normal results. Section D contains declarations by the patient and doctor that the sex of the fetus was not disclosed.

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    Sunscans

    Uploaded by

    Rajesh Pradhan
    15 views2 pages
    This document contains a form documenting a prenatal diagnostic test conducted on Sudha Rani. Section A provides patient details like name, age, address, last menstrual period. Section B documents the non-invasive ultrasound procedure conducted, including the doctor's name, indication for the test, date, and normal results. Section D contains declarations by the patient and doctor that the sex of the fetus was not disclosed.

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    This document contains a form documenting a prenatal diagnostic test conducted on Sudha Rani. Section A provides patient details like name, age, address, last menstrual period. Section B documents the non-invasive ultrasound procedure conducted, including the doctor's name, indication for the test, date, and normal results. Section D contains declarations by the patient and doctor that the sex of the fetus was not disclosed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views2 pages

    Sunscans

    Uploaded by

    Rajesh Pradhan
    This document contains a form documenting a prenatal diagnostic test conducted on Sudha Rani. Section A provides patient details like name, age, address, last menstrual period. Section B documents the non-invasive ultrasound procedure conducted, including the doctor's name, indication for the test, date, and normal results. Section D contains declarations by the patient and doctor that the sex of the fetus was not disclosed.

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    FORM F

    [Refer proviso to section 4(3) rules 9(4) and 10(1A)]


    FORM FOR MAINTENANCE OF RECORDS IN CASE OF PRENATAL DIAGNOSTIC
    TEST/ PROCEDURE BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE
    Section A:To be filled in for all Diagnostic Procedure Tests
    1. Name and complete address of the Genetic : Amruta scanning center
    Clinic/Ultrasound Clinic/Imaging Centre
    2. Registration no. (Under PC & PNDT Act, 1994) : 155/2022
    3. Patient’s Name : Sudha rani
    4. Age : 22
    4. Total Number of living Children : 0
    A. Number of living Sons with age of each living son : 0
    (in years or months)
    B. Number of living Daughters with age of each : 0
    living daughter (in year months)
    5. Husband’s/wife/Father’s/Mother’ Name” : Sachin sai
    6. Full Postal address of the patient with contact : Pathapatnam
    Number, if any
    7 Referred by (Full name and addresses of doctor : Self
    a. (s)/Genetic Counseling Centre
    (Referral Slips to be preserved carefully with form
    F)
    b. Self-Referral by : Self
    Gynecologist/Radiologist/Registered Medical
    Practitioner Conducting the diagnostic procedure
    (Referral note with indications and case papers of
    the patient to be preserved with form F)
    (Self-referral does not mean a client coming to a clinic and requesting for the test or the
    relative/s requesting for the test of a pregnant women)
    8. Last Menstrual period or weeks of pregnancy : 16-02-2023
    Section B: Tobe filled in for performing non-invasive diagnostic Procedures/Tests only
    9. Name of the doctor performing the procedure/s : Rajesh kumar
    10. Indication/s for diagnosis procedures : Estimation of gestational age (dating)
    11. Procedure carried out (Non-Invasive) Put a “Tick” on the appropriate procedures) :
    Ultrasound
    12. Date on which declaration of pregnant : 21-07-2023
    women/person was obtained
    13. Date on which procedure carried out : 21-07-2023
    14. Result of the non-invasive procedure carried out : Growth scan
    (report in brief of the test
    15. The result of pre-natal diagnostic procedures was : 21-07-2023On21-07-2023
    conveyed to
    16. Any indication for MTP as per the abnormality : Nill
    detected in the diagnostic procedures/test

    Name, Signature and Registration


    Numbers with seal of the Gynaecologist /
    Radiologist / Registered Medical Practitioner
    performing Diagnostic procedure/s
    Section C: Tobe filled for performing invasive Procedure/Test only
    17. Name of the doctor/s performing the procedure/s : NOT APPLICABLE
    18. History of genetic/medical disease in the family : NOT APPLICABLE
    (specify)
    19. Indication for the diagnosis procedure (“Tick” on
    appropriate indication)

    A. Previous child/children with : NOT APPLICABLE


    B. Advanced maternal age (35) : NOT APPLICABLE
    C. Mother/Father/sibling has genetic (specify) : NOT APPLICABLE
    D. Other (specify) : NOT APPLICABLE
    20. Date on which consent of pregnant : NOT APPLICABLE
    women/person was obtained if form G prescribed
    in PC & PNDT Act, 1994
    21. Invasive procedure carried out (“Tick” on : NOT APPLICABLE
    appropriate indication/s)
    22. Any complication/s of invasive procedure : NOT APPLICABLE
    (specify)
    23. Additional test recommended (Please mention if : NOT APPLICABLE
    applicable)
    24. Result of the Procedures/Test carried out (report : NOT APPLICABLE
    in brief of the invasive
    25. Date on which procedure carried out : NOT APPLICABLE
    26. The result of pre-natal diagnosis procedure was : NOT APPLICABLE
    conveyed to
    27. Any indication for MTP as per the abnormality : NOT APPLICABLE
    detected in the diagnostic procedures tests

    Name, Signature and Registration


    Number with Seal of the Gynecologist /
    Radiologist / Registered Medical Practitioner
    performing Diagnostic Procedure/s
    Section D: Declaration
    Declaration of the person undergoing prenatal diagnostic test/Procedure
    I, Mrs./Mr. Sudha rani declare that by undergoing Ultrasound Prenatal Diagnostic Test/Procedure. I
    do not want to know the sex of my foetus.
    Date: 21-07-2023
    Signature / Thumb impression of the person
    undergoing the prenatal Diagnostic Test / Procedure
    In case of thumb Impression
    Identified by (Name) Age Sex Relation (if any) Address and Contact No &
    Signature of person attesting thumb impression . Date
    Declaration of Doctor/Person Conducting

    Pre Natal Diagnostic Procedure/Test


    I, Rajesh kumar (name of the person conducting ultrasonography/image scanning) declare that while
    conducting ultrasonography/image scanning on M/s./ Mr. Sudha Rani (name of the pregnant women or the
    person undergoing per natal diagnostic procedure/test), I have neither detected nor disclosed the sex of her
    fetus to anybody in any manner.
    Signature

    Date: 21-07-2023
    Name in Capitals, Registration Number with Seal
    of the Gynaecologist/Radiologist/Registration Medical
    Practitioner Conducting Diagnostic procedure

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