Amendment status not verified — confirm the current text below against the official source.
I state that particulars filled by me in the form are true and correct to the best of my knowledge and nothing material has been concealed by me. Signature of the prospective donor (Full Name) Date [HTX I I - [ F M 3 ( i) ] HTTT d T TTtdT : V lT / T T 55 Note: To be sworn before Notary Public, who while attesting shall ensure that the person/persons swearing the affidavit(s) signs(s) on the Notary Register, as well. FORM 4 For certification of medical fitness of living donor (To be given by the Registered Medical Practitioner) [See proviso to rule 5(3)(b)] I, D r..................................................... possessing qualification o f.........................................registered as medical practitioner at serial no.......................... by the ....................................................................................................... Medical Council, certify that I have examined Shri/ Smt./ Km........................................................... S/o, D/o, W/o Shri .................................................. aged ................ who has given informed consent for donation of his/her ............................................... (Name of the organ) to Shri/Smt./Km ............................................................. who is a ‘near relative’ of the donor/other than near relative of the donor and has been approved by the competent authority or Authorisation Committee (as the case may be) and it is certified that the said donor is in proper state of health, not mentally challenged * and is medically fit to be subjected to the procedure of organ or tissue removal. Place:.................................. .................................................. Date: Signature of Doctor Seal To be affixed (pasted) here To be affixed (pasted) here Photograph of the Donor Photograph of the recipient (Attested by doctor) (Attested by the doctor) The signatures and seal should partially appear on photograph and document without disfiguring the face in photograph * In case of doubt for mentally challenged status of the donor, the Registered Medical Practitioner may get the donor examined by psychiatrist. FORM 5 For certification of genetic relationship of living donor with recipient (T o b e f i l l e d b y th e h e a d o f P a th o lo g y L a b o r a to r y c e r tify in g r e la tio n s h ip ) [See rules 5(3)(c) and 18(3)] I, Dr./M r./M r/M iss....................................................................... working as ........................................... at ........................................................ and possessing qualification of ..................................... certify that Shri/ Smt./ Km. ............................................................ S/o, D/o, W/o Shri/ Smt.................................................................................................. aged ...................... the donor and Shri/ Smt.......................................................................................... S/o, D/o, W/o Shri/Smt....................................................aged................. the prospective recipient of the organ to be donated by the said donor are related to each other as brother/sister/mother/father/son/daughter, grandmother, grandfather, grandson and granddaughter as per their statement. The fact of this relationship has been established / not established by the results of the tests for DNA profiling. The results of the tests are attached. Signature (To be signed by the Head of the Laboratory) Seal Place ..................................... D ate...................................... 56 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] FORM 6 For spousal living donor (to b e f i l l e d b y c o m p e te n t a u th o r ity * a n d A u th o r is a tio n C o m m itte e ,o f th e h o s p ita l o r d is tr ic t o r s ta te in c a se o f fo r e ig n e r s ) [See rule 18(2)] I, Dr./M r./Mrs/Miss.................................................................. possessing qualification of ..................................... registered as medical practitioner at serial No. .........................................by the ......................................................................................Medical Council, certify that:- M r........................................................................S/o................................................................................aged..........................resi dent of ............................................................................................. and M rs..............................................D/o, W /o...........................................................................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/........................................................................(Applicable only in the cases where considered necessary). OR In case the Clinical condition of Shri/Smt........................................................... mentioned above is such that recording of his/her statement is not practicable, reliance w ill be placed on the documentary evidence(s). (mention documentary evidence(s) here)....................................................................................................................... a. Marriage certificate indicate date of marriage b. Marriage photographs c. Date when transplantation was advised by the hospital ( to be compared with duration of marriage): d. Number and age of children and their birth certificates e. Any other document Signature of c o m p e te n t a u th o r ity * /A u th o r is a tio n c o m m itte e in c a se o f fo r e ig n e r s a lo n g w ith S e a l/S ta m p Place ..................................... D ate...................................... *Director or Medical Superintendent or In Charge of the hospital or the internal committee of the hospital formed for the purpose.as defined under the rules of Transplantation of Human Organ Act, 1994(42 of 1994). FORM 7 For organ or tissue pledging (T o b e f i l l e d b y in d iv id u a l o f a g e 1 8 y e a r o r a b o v e ) [See rule 5(4)(a)] ORGAN(S) AND TISSUE(S) DONOR FORM (To be filled in triplicate) Registration Number (To be allotted by Organ Donor Registry)........................... I ...........................................................................S/o,D/o,W/o...............................................................aged................................. ....and date of birth ........................................................................ resident of ....................................................................................in the presence of persons mentioned below hereby unequivocally authorise the removal of following organ(s) and/or tissue(s), from my body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes. Please tick as applicable (Following tissues can also be donated after [ HTX II-[F M 3(i) ] HTTT d T TTtdT : V lT / T T 57 brain stem death as well as cardiac death) Heart □ Corneas/Eye Balls □ Lungs □ Skin □ Kidneys □ Bones □ Liver □ Heart Valves □ Pancreas □ Blood Vessels □ Any Other Organ (Pl. specify) A ll Organs □ Any other Tissue (Pl. specify) A ll Tissues □ M y blood group is (if known)...................................................... Signature of Pledger...................................... Address for correspondence...................... Telephone No........................................ Email : .......................................... Dated: (Note: In case of online registration of pledge, one copy of the pledge w ill be retained by pledger, one by the institution where pledge is made and a hard copy signed by pledger and two witnesses shall be sent to the nodal networking organisation.) (Signature of Witness 1)