Contingency Fees Act, 1997
R 385.00
Choice on Termination of Pregnancy Act, 1996 (Act No. 92 of 1996)RegulationsAnnexuresAnnexure A |
ANNEXURE A
CHOICE ON TERMINATION OF PREGNANCY ACT, 1996 (ACT NO. 92 OF 1996)
NOTIFICATION OF TERMINATION OF PREGNANCY IN TERMS OF SECTION 7 OF THE ACT
FORM TO BE COMPLETED BY A MEDICAL PRACTITIONER OR A REGISTERED MIDWIFE
(To be completed in duplicate)
| 1. | Name of facility ............................................................................................................... |
| 2. | Age of woman requesting termination ............................................................................. |
| 3. | Where appropriate (encircle appropriate number); |
| 3.1 | Termination in terms of section 2(1)(a) or (b) of the Act. |
| 3.2 | Severe mental disability [section 5(4)(a) of the Act]. |
| 3.3 | Continuous unconsciousness [section 5(4)(b) of the Act]. |
| 4. | Race (mark with a cross): |
|
African |
Coloured |
Asian |
White |
Other |
If other, specify ................................................................................................................
5. Marital status (mark with a cross):
|
Single |
Living together |
Married |
Divorced |
Widowed |
6. Date of last menstrual period (LMP) .................................................................................
7. How many weeks into pregnancy? ....................................................................................
8. Number of previous pregnancies:
|
No. of live births |
No. of stillbirths |
No. of terminations |
No. of miscarriages |
9. Date of admission ............................................................................................................
Date of procedure ............................................................................................................
Date of discharge .............................................................................................................
10. Termination of pregnancy (mark with a cross):
|
(a) first 12 weeks |
(b) 13-20 weeks |
| 11. | Indication for termination of pregnancy (applicable only to terminations performed from 13th up to and including 20th week of gestation period (circle appropriate number): |
11.1 Woman's physical or mental health [section 2(1)(b)(i) of the Act].
11.2 Foetal physical or mental abnormality [section 2(1)(b)(ii) of the Act].
11.3 Rape or incest [section 2(1)(b)(iii) of the Act].
11.4 Social or economic circumstances [section 2(1)(b)(iv) of the Act].
Name of medical practitioner or registered midwife .........................................................
..........................................................................................................................................
|
Signed ...............................................
|
Date.....................................................
|
|
Qualifications .....................................
|
Registration number ............................ |
