THE TRANSPLANTATION OF HUMAN ORGANS RULES, 1995
(GSR NO. 51(E), dr. 4-2-1995)
[As amended vide GSR 571(E), dt.31-7-2008]


FORM 4
[Refer Rule 4 (1) (d)]


I, Dr. ............ possessing qualification of .................. registered as medical practitioner at Serial No .............. by the ............. Medical Council, certify that :-

(i)  Shri.......................... S/O Shri.............................. aged.........................resident of............................ and Smt.................... D/O, W/O Shri .................. aged........................... resident of........................ Are related to each other as spouse according to the statement given by them and their statement has been confirmed by means of following evidence before
effecting the organ removal from the 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.

 

Place
Date

Signature of Registered Medical Practitioner

FORM 5
[Refer rule 4(2) (a)]

  
I, ..........s / o, d / o, w / o Shri ............. aged .............. resident of ........... in the presence of mentioned below hereby unequivocally authorize the removal of my organ / organs, namely, .............. from my body after my death for therapeutic purposes.

Place
Date

Signature of Registered Medical Practitioner

  1. Shri / Smt. / Km. ............... s /o, w / o, d / o Shri ....................... aged ...................... resident of...................................
  2. Shri / Smt. / Km. ...........s /o, w / o, d / o Shri............. aged ................ resident of .............. is a near relative to the donor as ..............

Date...............................