1964_TERMINATION_OF_PREGNANCY_REGULATIONS — Page 4

CAP. 212] Termination of Pregnancy Regulations

[Subsidiary]

[1982 Ed.

L.N. 50/82.

CONFIDENTIAL

(*Delete as appropriate)

(Ring appropriate number)

(Ring appropriate letter)

I,

of

and I.

of

FORM 2

[reg. 3.]

Not to be destroyed within five years of the date of operation

OFFENCES AGAINST THE PERSON ORDINANCE (Chapter 212)

CERTIFICATE TO BE COMPLETED IN RELATION TO THE TERMINATION OF A PREGNANCY IN EMERGENCY UNDER SECTION 47A(4) OF THE ORDINANCE

1. Name and qualifications of practitioner in block capitals;

2. Full address of practitioner;

3. Name and qualifications of practitioner in block capitals;

4. Full address of practitioner;

hereby certify that we

are* / were*

of the opinion, formed in good faith, that it

is* / was*

immediately necessary to terminate the pregnancy of

Full name of pregnant woman in block capitals

of

Usual place of residence of pregnant woman in block capitals,

in order-

1. to save the life of the pregnant woman; or

2. to prevent grave permanent injury to the physical or mental health of the pregnant woman,

This certificate of opinion is given-

A. before the commencement of the treatment for the termination of the pregnancy to which it relates;

or, if that is not reasonably practicable, then

B. not later than 24 hours after such termination.

Signed

Signed

Date

Date