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FORM
-4
[(See rule 4(1) (d)]
I, Dr. ...................................
possessing qualification of
…………………… registered as
medical practitioner at Serial No. .......................... by the
..............................................,
Medical council,
certify that :-
(i)
Mr.
………………………………………………………………..
S/o
……………………………………………………..
aged ………………
. resident of
…………………………………………….. and
Mrs.
…………………………………………………………………
D/o, W/o
…….………………………………………………….. aged
..........................................................
resident ............. ............
..... are
related to each other as spouse a according to the statement
given
by them and their statement has been confirmed by means of
following evidence before effecting the organ removal from body of
the
said Shri / Smt /
Km......................................…………………………
(Applicable
only in the cases where considered necessary).
(Or)
(ii)
The Clinical condition of Shri/Smt...............................
........... mentioned above is such that recording of
his/her
statement is not practicable
Signature of Regd. medical practitioner
Place.........................
Date...........................
FORM
-5
[(See rule 4(2) (a)]
I
............................S/o, D/o, W/o ......................
...... ..
aged ...................................... resident of
.................
in the presence of persons mentioned below
hereby unequivocally
authorise the removal of my organ/organs,
namely, ...................
from my body after my
death for therapeutic purposes.
Dated................................
Signature of the Donor
(Signature)
1.
Shri/Smt./Km.................................................................................
S/o,
D/o, W/o
................................................................................…
………………aged ..... ....... ............. ..............
resident of .............................. ..................
......................…... ………………………………
……………………… ………
………………………………
(Signature)
2.
Shri/Smt./Km...................................................................................
............................……………..aged
.....................................……………….. resident of
............................................…….is a near relative to
the donor
as.............................................................................................
Dated....................................................
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