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Home \ THOA - Review Committee \ FORM 2
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TRANSPLANTATION OF HUMAN ORGANS


The Report Of Transplant of Human Organs Act - Review Committee
FORM 2

TRANSPLANTATION OF HUMAN ORGANS
The Transplantation of Human Organs Act, 1994
The Transplantation of Human Organs Rules - 1995 (GSR 571(E), dt.31-7-2008)
The Transplantation of Human Organs Rules - New Forms - 1995 (GSR 571(E), dt.31-7-2008)
The Transplant of Human Organs Act - Review Committee

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)]


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