The Transplantation of Human Organs Rules, 1995 - Form 4

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 …….………………………………………………………… ………………….. ............................................. 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...........................