The Transplantation of Human Organs Rules, 1995 - Form 10

FORM -10 

 APPLICATION FOR APPROVAL  FOR TRANSPLANTATION LIVE DONOR OTHER THAN  NEAR RELATIVE

Whereas I ....................................................S/O, D/O, W/O, L/O.............................aged
residing...................................................................have been informed by my doctor that I am suffering from.......................and may be benefitted by transplantation ......................... into my body.
 and whereas I ......................................................…………………………….. S.O. D.O. W.O......................................... aged .................. residing at..........................................by reason of affection and attachment because : ...............................................................................................
..............................................................................................................................................
(reason to be filled in) would like to donate  my....................................to............................we................................. (donor) and............................................hereby apply to authorisation committee for permission      (Recipient) for such transplantation to be carried out.

        We solemnly affirm that the above decision has been taken without any undue pressure, inducement, influence or allurement and that all-possible consequences and options of organ transplantation have been explained to us........................................................................................................................................
............................................................................................................................................
 

Signature and address of prospective                  Signature and address of prospective   donor                                                                      recipient