Schedule-11 (Relating to Clause (a) of Rule 7)
Contents to be certified by the concerned doctor that organ transplantation is necessary
We hereby certify, pursuant to Clause (a) 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), that
we 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 sa ve his/her life.
Certifying nephrologist’s:
1. 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. 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: