The Transplantation of Human Organ Rules 1995 FORM 2

¹[FORM 2

[To be completed by the concerned medical practitioner]

[Refer rule 4(1) (b)]

I, Dr. ……………………… possessing qualification of …………………………..

registered as medical practitioner at Serial No. …………………….. by the

…………………………… Medical Council, certify that I have examined Shri/Smt./ Km

……………….. s/o, w/o, d/o Shir ……………… aged ………………who has given in-formed consent about donation of the organ, namely (name of the organ ………………………….. to Shri/Smit./Km ………………………………….. who is a “near relative” of the donor / other that near relative of the donor, who had been approved by the Authorisation Committee / Registered Medical Practitioner i.e. In-charge of transplant center (as the case may be) 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 …………………… ………………………….

Date ……………………. Signature of Doctor

seal

Photograph of the Donor Photograph of the Recipient

(Attested by doctor) (Attested by doctor)]