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