1[FORM 2]
[To be completed by the concerned medical practitioner]
[Refer rule 4(1) (b)]
|
I, Dr. ...............possessing qualification of ................... registered as medical practitioner at Serial No. ............... by the ................Medical Council, certify that I have examined Shri/Smt./ Km ............... s/o, w/o, d/o Shir ..................aged ...............who has given in-formed consent about donation of the organ, namely (name of the organ ................ to Shri/Smit./Km ....................... who is a “near relative” of the donor / other that near relative of the donor, who had been approved by the Authorisation Committee / Registered Medical Practitioner i.e. In-charge of transplant center (as the case may be) and that the said donor is in proper state of health and is medically fit to be subjected to the procedure of organ removal.
|
| Place ......................... |
................................
|
| Date .......................... |
Signature of Doctor seal
|
|
To be affixed (pasted) and attested by the doctorconcernedThe signatures andseal should partiallyappear on photograph and document without disfiguring the face in photograph
|
|
|
To be affixed (pasted) and attested by the doctorconcernedThe signatures andseal should partiallyappear on photograph and document without disfiguring the face in photograph
|
|
Photograph of the Donor
(Attested by doctor) |
Photograph of the Recipient
(Attested by doctor)] |
|
|
1[FORM 3
[Refer rule 4(1) (c)]
|
|
I, Dr./Mr./Mrs.. ..…………………….working as ………………………at …………………………… and possessing qualification of ……………………..certify that Shri / Smt. Km. ………………………………………. S / o, D / o, Wo Shri / Smt. ………………………………………. aged ……………….. the donor and Shri / Smt. ………………………. S / o, D /o, W/o, Shri / Smt ……………….. aged ……………… the proposed recipient of the organ to be donated by the said donor are related to each other as brother / sister / mother /father /sons /daughter as per their statement and the fact of this relationship has been established / not established by the results of the tests for Antigenic Products of the Human Major Histocompatibility Complex. The results of the test are attached
|
| Place............................. |
|
| Date............................... |
Signature
(To be signed by the Head of the Laboratory)
|
|
Follow us on Twitter
Become a Fan of MOHAN Foundation
