FORM 9
(See rule 4(3) (b))
I, Mr/Mrs....................................son of / wife of
....................... resident of ...........................hereby
authorise removal of the organ/organs namely .......................for therapeutic purposes from the dead body of my son/daughter . Mr/Ms ...............................
aged......... whose brain stem death has been duly certified
in accordance with the law
Signature..............................
Name.................................
Place...................................
Date..................................
FORM -10
APLICATION FOR APPROVAL FOR TRANSPLANTATION
LIVE DONOR OTHER THAN NEAR RELATIVE
Whereas I ....................................................
S/O, D/O, W/O, L/O. ............... aged residing..............................have been informed by
my doctor that I am suffering from.......................and
may be benefitted by transplantation .........................
into my body. and whereas I .....…………………… S.O. D.O. W.O............................. aged .................. residing at..............................by reason of affection and
attachment because :
..............................................................................
...............................................................................
(reason to be filled in) would like to donate my ..................
to ........................we................................. (donor) and ....................... hereby apply to authorisation committee
for permission (Recipient) for such transplantation to be
carried out. We solemnly affirm that the above decision has
been taken without any undue pressure, inducement, influence
or allurement and that all-possible consequences and options
of organ transplantation have been explained to us.
...................................................................................
.................................................................................... Signature and address of prospective
donor recipien
|
Form - 9 & 10 |
-ACT,-2011.gif){kind=spacer}
