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Get Form F See Proviso To Section 43 Rule 94 And Rule 101a

8. 9. 10. Name and address of the Genetic Clinic/Ultrasound Clinic/Imaging Centre. Registration No. Patient s name and her age Number of children with sex of each child Husband s/Father s name Full address with Tel. No., if any Referred by (full name and address of Doctor(s)/Genetic Counseling Centre (Referral note to be preserved carefully with case papers)/self referral Last menstrual period/weeks of pregnancy History of genetic/medical disease in the family (specify) Basis of diagnos.

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