Indian Society of Nephrology - West Zone Chapter

THO Form

1[FORM 1(A)
[To be completed by the prospective related donor]
[Refer rule 3]

My full name is .............................................And this is my photograph

Photograph of the Donor
(Attested by Notary Public)

To be affixed and attested by Notary Public after it is affixed.

My permanent home address is
......................................................................................................
.................................................................Tel:.................................
My present home address is
......................................................................................................
..................................................................Tel:................................
Date of birth............................(day/month/year)

• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached)
and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached)
and/or
• Passport number and country of issue .............................................(Photocopy attached)
and/or
• Driving Licence number, Date of issue, licensing authority ...........................................
and/or
• PAN..............................................................
and/or
• Other proof of identity and address..........................................................

I hereby authorize removal for therapeutic purposes/consent to donate my ................ (state which organ) to my relative (specify son / daughter / father / mother / brother / sister), whose name is ........... ..........................and who was born on ..........................
(day / month / year) and whose particulars are as follows:

Photograph of the Donor
(Attested by Notary Public)

To be affixed and attested by Notary Public after it is affixed.

• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached)
and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached)
and/or
• Passport number and country of issue .............................................(Photocopy attached)
and/or
• Driving Licence number, Date of issue, licensing authority ...........................................
and/or
• PAN..............................................................
and/or
• Other proof of identity and address ...........................................

I solemnly affirm and declare that:-
Sections 2, 9, and 19 of the transplantation of Human Organs Act, 1994 have been explained to me and I confirm that: -

I understand the nature of criminal offences referred to in the sections.
No payment of money or money’s worth as referred to in the sections of the Act has been made to me or will be made to me or any other person.
I am giving the consent and authorisation to remove my ........................... (organ) of my own free will without any undue pressure, inducement, influence or allurement.
I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my...................................(organ). That explanation was given by ........................... (name of registered medical practitioner).
I understand the nature of that medical procedure and of the risks to me as explained by that practitioner.
I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place.
I state that particulars filled by me in the form are true and correct to my knowledge and nothing material has been concealed by me.

..........................................

...............

Signature of the prospective donor

Date

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.
• √Wherever applicable.

THO Form

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