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FORM
- 2
[(See rule 4(1) (b)]
I,
Dr.
........,
possessing the qualification of
........
registered as medical
practitioner at serial No. .................
by the
....................................... Medical as Medical Council,
certify that I have examined Shri / Smt / Kum.
............................. S/o, D/o, W/o
......................................................... aged
................................ who is free and is near relative of
the donor 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:
..........................
Signature
Date:
......................
FORM
-3
[(See rule 4(1) (c)]
I,
Dr........................................
possessing the qualification of
..
registered as med. practitioner at Serial No. ................ by the ..........................
..................... Medical council, certify that Mr. /Mrs.
....................
.................................................... S/o, D/o, W/o
aged
..
............................the donor, an Mr./Mrs.
S/o, D/o,
W/o
aged
........................., the recipient of the organ donated by the
said donor are related to each other as
brother/sister/mother/father/son/daughter as per their statement and
the fact of this relationship has been established by the results of
the tests for Antigenic Products of the Human Major
Hysto-compability System, namely
....................................................... by the
Authorisation Committee as per the information contained in their
letter of approval No.
....................................................................
dated .......................
Place..........................
Signature
Date..........................
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