Schedule-16
(Relating to Clause (d) of Rule 8)
Deed of consent to be executed by recipient of kidney or person on
behalf of such person
To…………………,
…………………….
Whereas, I/he/she ………………….. , age of …………….. years, a resident  of Ward No…………., VDC/Municipality ………………….., ………………………. District, have/has been suffering from kidney related ………….. disease,
I/he/she have/has got my/his/her health checked up by the concerned doctor; and the doctor has certified that both kidneys in my/his/her bodies have been deformed to be unworkable and it is necessary to transplant one kidney in
lieu of such deformed kidney for the safety of my/his/her life; and  Whereas, the donor ………………… has given consent on …………………. (date) to extract kidney from his/her body during his/her life/after death and
transplant the same into my/his/her body or body of any person whosoever for purposes of my/his/her medical treatment; and I/he/she agree/agrees to receive the kidney of the said donor through transplantation pursuant to Subsection
(1) of Section 19 of the Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998) and Rule 12 of the Human Body Organ Transplantation (Regulation and Prohibition) Rules, 2058  (2002);
Now, therefore, I have executed this deed of consent to that effect.
Person consenting to receive kidney:
Name:
Signature:
Date:
Grand-father’s name:
Father’s name:
Relationship with patient:
Address:
Date:
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