Mohan Foundation(Multi Organ Harvesting Aid Network)-THO Form

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TRANSPLANTATION OF HUMAN ORGANS

The transplantation of human organs Act, 1994 (Central Act 42 0f 1994)

TRANSPLANTATION OF HUMAN ORGANS

Forms from THO Rules 2014

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

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