No 1 shall be made in any case-sheet, operation theater register, follow-up card 01 other document or register other than the admission Register maintained al hospital or approved place indicating therein the name of the pregnant we and reference to the pregnant woman shall be made therein by the serial nu assigned to the woman in the Admi sion Register.
12 The Medical Termination of Pregnancy Regulations, 2003 [Reg. , Form II] The Medical Termination of Pregnancy Regulations, 2003 13 FORM I (See regulation 3) 'amt· and qualihcabo~of the Registered Medical Practitioner III block letters) (Full addr~s of the Registered looical Practitioner) amt' and quahfications of the Registen.'d . fc'Chcal Prachhoner in block letters}_...._-- - -_.._----_._._---- lFull addJ'l"'- ot the R~tt.'red \tedlcal Practitioner) hereby ccrb.~ that -I/\\.e am/are of opinion, turmt.od Ul i;Olld faith. that it j neces.sar\' to temunate the pn..-gn.mn of ._ _ __ .
Signature of the R~stered Medical Practitioner Signature of the Registered \1edical Practitioners
(iv)
(v) (Full narnt;.> ld p~ant woman in block letters) Te"ldent of • ~Full addre<>~ of pregnant woman in block letters) for the reasons given belo\\ •• • I \\1.' hcreb~ gi\l! mtimation that ·I,We tennmated the pn."gJlan0 of the woman referred to abme \\ho bean. thc serial No. ... o ••• in the Admi.!-... ion Rt-giskr of the hospital/approved place.
Plal.:t.."
Date.
Strike out \,"ruche\ er ~ not applicable.
"ot thl' rca!-.Oru. !'peeified Items (il to (v) write the one which is appropriate:-
(i) In order to save the life of the pregnant woman,
(il) In order to prevent grave injury to the phy~ical and mental health of the pregnant woman,
(iii) in view of the substantial risk that if the child W,JS born it would suffer from such physical or mental abnormalities as to be seriously handicapped, as the pregnancy is alleged by pregnant woman 10 have been caused by rape, as the pregnancy has occurred as result of failure of any contraceptive device or methods used by married woma" or her husband for the purpose of limiting the number of children Note.-Account mol\" be taken of the pregnant woman's actual or rcasonabl~ foreseeable environment an determlnlOg whether the continuance of her pregnancy would lOvolve a grave injury to her phv'tical or mental health.
Place. Signature of the Registered Medical Practitioner/Practitioners Date.
FORM 11 [See regulation 4(5)1 ~ame 01 the State :2. :'\amc ot the Hor-pital/appro\'ed place
3. Durahon of pregnancy (gi\."e total ,,",0. only) (a. Up to 12 \\'eeks.
(b) Bt-tween 12 • ~O weeks 4 ReliJtlon ot \\ oman lal Hmdu
(b) \1u>1un iC) elm! ban ld) Other" leI Total ::; Termmahon With acceptance of contraception
(a) Sterh.sabon (bJ IUD 14 The Medical Termination of Pregnancy Regulations, 2003 [Form II
0. Rca..-.ons for tennrnation:
I e tot,ll number under each ·ub·hcad)
(a) Dan er to life of the pregnant woman.
(b) rave injury to the phy~ical health of the pr gnant woman.
(c) rav injury to the mental health of the premant woman.
d) Pregnancy caused by rape.
(e) ub~tantial TIS that if the child wa.· born. It \ 'ould uffer from ueh ph •'ieal or m ntal abn rmalities a to be >ri u~l) handicapped.
(f) FaUuT of any conrracepti\e dc\ ice or method ignature 0 the Officer Incharge wlth Date FO III (-t!,. regulation 5) D J JO REGI TER (To be d trO\'ed on the e piry of five yea trom th date of the la t entry in the Register) I 2 3 .j, 5 6 7 S. '0. Nam of Name of th Wife/Daught r Ag Religion Addre Admission Patient of I I 8 9 10 11 12 13 14 Duration Reasons on Date of Oat of Re ult arne of am of f which termination discharg of ilnd Registered Registered Pregnancy Pr gnancy is of patient Remarks MedicaL M dical t rminated Pregnane Pracli lioner (s) Practitioner (.)
b whom the by whom pinion is Pregnancy i formed terminated ••• MTP ACT 1971 (1) 13.pdf MTP ACT 1971 (1) 14 MTP ACT 1971 (1) 15 MTP ACT 1971 (1) 16