THE TRANSPLANTATION OF HUMAN ORGANS ACT, 1994
(Central Act 42 0f 1994)

 

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