1[FORM 2
[To be completed by the concerned medical practitioner]
[Refer rule 4(1) (b)]
I, Dr.
possessing qualification of
..
registered as medical practitioner at Serial No.
.. by the
Medical Council, certify that I have examined Shri/Smt./ Km
.. s/o, w/o, d/o Shir
aged
who has given in-formed consent about donation of the organ, namely (name of the organ
.. to Shri/Smit./Km
.. who is a near relative of the donor / other that near relative of the donor, who had been approved by the Authorisation Committee / Registered Medical Practitioner i.e. In-charge of transplant center (as the case may be) and that the said donor is in proper state of health and is medically fit to be subjected to the procedure of organ removal.
Place
.
Date
. Signature of Doctor
seal
|
To be affixed (pasted) and attested by the doctor
concerned
The signatures and
seal should partially
appear on photograph and document without disfiguring the face in photograph. |
|
To be affixed (pasted) and attested by the doctor
concerned
The signatures and
seal should partially
appear on photograph and document without disfiguring the face in photograph. |
Photograph of the Donor Photograph of the Recipient
(Attested by doctor) (Attested by doctor)]
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