Schedule-13

Schedule-13
(Relating to Clause (a) of Rule 8)
Deed of consent to be given by alive person to donate kidney Whereas, for purposes of Section 15 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998), I ………………. and my near relative ………………………. by relation ………………. have agreed and concurred to extract one kidney from my body
and transplant it into the body of my close relative …………………. who is my …………………… by relation;
Now, therefore, I have given this deed of consent, pursuant to Clause (b) of Sub-section (1) of Section 15 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998) and Clause (a) of Rule 7 of the Human Body Organ Transplantation (Regulation and Prohibition) Rules, 2058 (2002).
Donor of kidney: Recipient of kidney:
Name: Name:
Grand-father’s name: Grand-father’s name:
Father’s name: Father’s name:
If married, If married,
husband’s or wife’s name: husband’s or wife’s name:
Age: Age:
Address: Address:
Signature: Signature:
Recently taken passport Recently taken passport
size photograph size photograph
with two ears being visible with two ears being visible
Thumb impressions
Right Left
Close relative of donor of kidney:
(a) Name:
Age:
Address:
Relation:
Signature:
Thumb impressions:
Right Left
(b) Name:
Age:
Address:
Relation:
Signature:
Thumb impressions:
Right Left