1982 Ed.] Termination of Pregnancy Regulations
[CAP. 212
15.
Was sterilization performed?
Yes
Complications or death prior to notification-
16.
(a) None
(b) Sepsis
(c) Haemorrhage
(d) Death
(e) Other (specify)
17.
In the case of death, specify the cause-
No
Now: This form is to be completed by the operating medical practitioner and sent in a sealed and confidential envelope not later than 3 days after the termination of the pregnancy to the Director of Medical and Health Department, Hysan Avenue, Hong Kong.
機
表格三
(中斷妊娠規例第四條)
侵害人身罪條例
(香港法例第二一二章)
根據條例第四十七A條施行中斷妊娠手術後向醫務衛生署署長申報之通知書
本人……
地址為
茲申報:本人已替孕婦
(用楷書填寫醫生姓名及學歷)
(醫生之詳細地址)
(用楷書填寫孕婦全名)
地址為……
(用楷書填寫孕婦通常居住之地址)
……
.施行中斷妊娠手術。
手術日期,
.時間……
必須施行中斷妊娠手術之理由業經證明如下
該孕婦如繼續懷孕,對性命所造成之危險較中斷妊娠爲大;
該孕婦如繼續懷孕,身體或精神所受之損害較中斷妊娠爲大;
如讓嬰兒誕生,則該嬰兒大有可能身體或精神不健全而致嚴重傷殘。
All
[Subsidiary]
(Ring appropriate answer)
(Ring appropriate letter)
甲,(此欄必須 填寫)
乙、(此欄必須 填寫 )
( 圈出一項適當 者)