Department of Genetic Medicine

Sir Ganga Ram Hospital

Rajinder Nagar, New Delhi – 110060

Telephone No: 52252139  (Direct), 25861743, Ext 2139

Fax : 91 11 25861767, 25861759. Email: dr_icverma@yahoo.com 
 
 

Department of Genetic Medicine

Sir Ganga Ram Hospital

Rajinder Nagar, New Delhi – 110060 
 
 
 
 
 
 
 
 

Form E, [Rule 9 (3)] 
 

Registration No. 
 

RECORD TO BE MAINTAINED BY THE GENETIC LABORATORY

For Those Patients Undergoing Prenatal Diagnosis 
 

1. Patients Name

2. Age

3. Husbands /Father's name

4. Full address with Tel. No. If any

5. Referred by / Sample sent by (full name and address)

6. Type of sample: Maternal blood / Chorionic villus sample / Amniotic Fluid / Foetal blood or other Foetal tissue; (Specify)

7. Specify Indication for Prenatal Diagnosis

1. Previous Child / children with
   1. Chromosomal disorders   ii. Metabolic disorders

3. Malformation (s)     iv. Mental retardation

v.     Hereditary haemolytic anaemia vi. Sex-linked disorder

      vii     Any other disorder (specify) 
 

2. Advanced maternal age (-35 years)

3. Mother/father/sibling has genetic disease (specify)

4. Other indication ( specify)

8. Laboratory tests carried out (give details)

i.  Chromosomal studies    ii. Biochemical Studies                 iii.  Molecular studies 
 
 

9. Result of Prenatal Diagnosis Normal / Abnormal

   if abnormal give details 
 

10. Date (s) on which tests carried out

The Results of the Prenatal Diagnostic Tests were Conveyed to ....………… or ……………................. 
 
 

Date      Name, Signature of the Scientist / Geneticist      Registration No. if applicable

Department of Genetic Medicine

Sir Ganga Ram Hospital

Rajinder Nagar, New Delhi – 110060

Telephone No : 52252139  (Direct), 25861743, Ext 2139

Fax : 91 11 25861767, 25861759. Email : dr_icverma@yahoo.com 
 

CONSENT FORM FOR PRENATAL DIAGNOSTIC TESTS

I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . wife of. . ……………….. 
 

Resident of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . 
 

request and authorize the Scientific Staff of Genetic Laboratory, Dept. of Genetic Medicine Sir Ganga Ram Hospital, New Delhi to carry out Prenatal Diagnostic Tests indicated below 
 

1. Chromosomal studies  2. Molecular studies  3. Biochemical studies 
 
 
 
 
 

on   Chorionic villus samples.   Amniotic fluid sample.