The Transplantation of Human Organ Rules 1995 FORM 4

FORM 4

[Refer Rule 4 (1) (d)]

I, Dr. ……………….. possessing qualification of ……………….. registered as medical practitioner at Serial No. ………………… by the …………………… Medical Council, certify that –

(i) Shri. ………………… s/o Shri …………………… aged ……………

resident of ……………………… and Smt …………………D / o, w / o

Shri …………………………………… aged ………………….. resident of …………………. Are related to each other as spouse according to the

statement given by them and their statement has been confirmed by

means of following evidence before effecting the organ removal from

the 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.

Place …………………… Signature of Registered Medical Practitioner

Date …………………...