Transplant of Human Organs - Forms 2,3,4,5,6,7

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

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

FORM -6
[(See rule 4(2) (b)]
I..................................................................s/o,d/o,w/o........................................aged.................
resident of................................................................................having lawful possession of the dead body Sri/Smt/km........................s/o,d/o,w/o....................................................................aged...........
of........................................................................................................having} known that the deceased has not expressed any objection to his/her organ/organs being removed for therapeutic purposes after his/her death and also having reasons to believe that no near relative of the said deceased person has objection to any of his/her organs being used for therapeutic purposes authorise removal of his/her body organs, namely..............................................
Dated............................... Signature
Place …………………... Person in lawful possession of the dead body
Address..................................................................................
...............................................................................................

FORM -7
[(See rule 4(2) (b)]
I, Mr/ Mrs./Miss.....................................................................having lawful possession of the deadbody of Mr/ Mrs./Miss............................................................son of/ daughter of / wife of ..................... ............ aged .................................. resident of ........................................after having known that the objection was expressed by the deccased to any of his human organs being used after is death for therapeutic purposes and having reason to believe of deccased person has objection to any of the deccased person's organs being used for therapeutic purposes, hereby authorise the removal of the deceased’s organ, namely, ………………………………………………. for therapeutic purposes. Signature........................................................
Name..............................................................
Address..........................................................
.......................................................................
Time and Date ……………………………...