TRANSPLANTATION OF HUMAN ORGANS

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....................................................