Schedule-12

Schedule-12
(Relating to Clause (b) of Rule 7)
Contents to be certified by the concerned doctor
that donor of kidney will have no physical effects
Whereas, certification has been made on……………………. (date) by nephrologists Mr/Mrs/Ms………………………… and Mr/Mrs/Ms………………… that they have examined the health of Mr/Mrs/Ms………………………………….
(name of patient), age of …………… years, a resident of ………………………….., and found that his/her both kidneys in his/her body are non-functional and that it is necessary to transplant one kidney in lieu of the
destroyed kidneys in his/body in order to save his/her life; and Whereas, on…………………. (date), Mr/Mrs/Ms…………………………  (name of donor), age of………… years, a resident of ………………….. years,
has, for the transplantation of kidney into the body of patient, executed a deed of consent to extract one kidney out of his/her twin kidneys in his/her body and transplant the kidney into the body of the patient;
Now, therefore, pursuant to Clause (d) of Sub-section (1) of Section 15 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998) and Clause (b) of Rule 7 of the Human Body Organ
Transplantation (Regulation and Prohibition) Rules, 2058 (2002), we hereby certify that the donor so giving c onsent to donate the organ will neither die imediaely nor become disabled or incapacitate d in a permanent
manner a s a re sult of extraction of any organ out of the tw in organs of the body of that donor.
1. Certifying nephrologist’s:
Full name and surname:
Signature:
Date:
Registration number of Nepal Medical Council:
Name of health institution being engaged in:
Seal of health institution being engaged in:
2. Certifying surgeon’s:
Full name and surname:
Signature:
Date:
Registration number of Nepal Medical Council:
Name of health institution being engaged in:
Seal of health institution being engaged in: