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