FORM C (See Rule 8) I ________________________________________daughter/wife of_______________________________ ________________________________aged about_____________________________years of__________ ______________________________________________________________________________________at (here state the permanent address) Present residing at_________________________________________________________________________ do hereby give my consent to the termination of my pregnancy at___________________________________ (state the name of place where the pregnancy is to be terminated). Place : Date: Signature (To be filled in by guardian where the woman is a lunatic or minor) I,_____________________________________________________________________ son/daughter/wife of ____________________________________________________aged about ______________________years of _____________________________________________________________________________at present (Permanent address) residing at_______________________________________________________________________________ do hereby give my consent to the termination of the pregnancy of my ward___________________________ who is a minor/lunatic at _________________________________________________________ (Place of termination of pregnancy) Place : Date: Signature
