N. B.— (Blood from the body of the above named __________ was collected by me for chemical examination). __________ was not
Dated __________ 20 __________. (Signature)
Designation
Signature/Thumb-impression of the person examined.
Marks of identification of the person examined in case he refuses to give his signature or thumb-impression.
See rule 4 (2)
From
(Name, designation and address of the registered medical practitioner)
To
(Name, designation and address of the Testing Officer.)
Dated __________ 20 __________.
Sir
I forward herewith by post/with Shri * __________ of __________ a phial bearing serial No __________ containing __________ c. c. of venous blood collected by me on __________ at __________ a.m./p.m. of __________ who was produced before me for medical examination †and/or collection of blood from his/her body† by ‡ __________ and request you to test the blood and issue a certificate (in duplicate) regarding the result of the test.
Yours faithfully,
Signature and designation of the registered medical practioner.
Facsimile of the seal or monogram used for sealing the phial containing the blood.
* Here specify the name, designation and address of the messenger with whom the phial containing the blood is forwarded for delivery to the Testing Officer.
† Strike off if these words are not required.
‡ Here state the name and designation of the officer by whom the said person was produced for collection of blood.
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