Schedule-15
(Relating to Clause (c) of Rule 8)
Deed of consent to be given by close relative of deceased to extract
kidney after death
To………….,
………………
Whereas, my/our close relative deceased ………………….. has, for purposes of Section 14 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998), knowingly and voluntarily given consent to extract kidney from his/her body after his/her death and transplant the same in the body of any person whosoever and executed a deed of consent on ……………… (date), pursuant to Clause (b) of Sub-section (1) of Section 16 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998) and Clause (b) of Rule 8 of the Human Body Organ Transplantation (Regulation and Prohibition) Rules, 2058 (2002), and now he/she has died; and Whereas, I/we, the below-mentioned close relative/relatives, concur to extract kidney from his/her body as per his/her will; Now, therefore, I/we have executed this deed of consent pursuant to Clause (c) of Rule 8 of the Human Body Organ Transplantation (Regulation and Prohibition) Rules, 2058 (2002).

Close relative giving consent to donate kidney of deceased:
Name: Name:
Signature: Signature:
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:
Relationship with deceased: Relationship with deceased:
Address: Address:
Date: Date:
Thumb impressions Thumb impressions
Right Left Right Left