Concerning my wish not to have an Ante Natal Screening Test
Patients Surname ...................................................
Forenames ...........................................................
Date of Birth .........................................................
Hospital ...............................................................
Health Authority ....................................................
Unit Number .........................................................
I confirm that I have explained to the patient the purpose of the ante natal screening test(s)
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I confirm that I have explained that if the test(s) shows that the unborn may be affected by an inherited disease she would be advised to consider an abortion under the terms of the Abortion Act 1967.
I have also explained to her that ante natal tests for the benefit of herself or her baby are not to be excluded by this form.
I confirm that I have explained the nature of the investigation, or operation, in the terms which in my judgement are suited to the understanding of the patient and/or one of the parents or guardians of the patient.
Signature Doctor/Midwife
........................................................................ Date ................
Name and status of Doctor or Midwife
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I DO NOT WISH TO HAVE ANTE NATAL SCREENING TESTS WHICH ARE NOT NEEDED FOR THE CARE OF MY PREGNANCY OR THE FUTURE HEALTH OF MY BABY
PATIENT/PARENT/GUARDIAN
- Please read this form carefully
- If there is anything that you don't understand about the explanation, or if you want more information, you should ask the doctor or midwife.
- Please check that all the information on the form is correct. If it is, and you understand the explanation, then sign the form.
I am the patient/parent /guardian (delete as necessary)
Signature
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Name
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Witness
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Address
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