The Transplantation of Human Organs Rules, 1995 - Form 3

FORM -3
[(See rule 4(1) (c)] 

I,Dr...............................................possessing the qualification of .....................     …………………………………… registered as med. practitioner at Serial No. .............................. by the .......................... ..................... Medical council, certify that Mr./Mrs. …………………………… .S/o, D/o, W/o ............................……………aged ...............the donor, an Mr./Mrs. …………… ……… ……… S/o, D/o, W/o ………………………………… aged ........................., the recipient of the organ donated by the said donor are related to each other as brother/sister/mother/father/son/daughter as per their statement and the fact of this relationship has been established by the results of the tests for Antigenic Products of the Human Major Hysto-compability System, namely .......................................... by the Authorisation Committee as per the information contained in their letter of approval No. .................................................. dated .......................

Place..........................                                                                                                    Signature

Date..........................