The Transplantation of Human Organ Rules 1995 FORM 3

¹[FORM 3

[Refer rule 4(1) (c)]

I, Dr./Mr./Mrs.. ..……………………. working as ……………………… at ……………………………… and possessing qualification of …………………….. certify that Shri / Smt. Km. ………………………………………. S / o, D / o, Wo Shri / Smt. ………………………………………. aged ……………….. the donor and Shri / Smt. ………………………. S / o, D /o, W/o, Shri / Smt ……………….. aged ……………… the proposed recipient of the organ to be donated by the said donor are related to each other as brother / sister / mother /father /sons /daughter as per their statement and the fact of this relationship has been established / not established by the results of the tests for Antigenic Products of the Human Major Histocompatibility Complex. The results of the test are attached.

Place ………………………….

Signature

(To be signed by the Head of the Laboratory)

Date ………………………….