Professional Documents
Culture Documents
Documentation Kidney Transplant
Documentation Kidney Transplant
AFFIDAVIT
I,_________________________________S/o,
Rajesh J. Jaiswal D/o, W/o, _________________________
R/o ____________________________________________ , hereby solemnly affirm and
declare as under:-
without any pressure or undue influence from any side. Neither I have sold nor I have
Verification :
Verified at this 4th day of october 2022 that the contents of the
above affidavit are true and correct to the best of my knowledge and belief, and nothing
material has been concealed therefrom.
Affidavit
I _________________________________
Ben Marshall S/o, D/o, W/o ______________________________
R/o____________________________________________ Hereby solemnly affirm and declare on
oath as given hereunder:- Washington DC, District Attorney.
2. That I am first time appearing before the Authorisation Committee of Human Organ
Transplantation Committee of Washington DC-The Medicity, Gurgaon, Haryana and the deponent
will not undergo any litigation against the authorization committee and Medanta-The
Medicity and have not appeared before any authorization Committee of any other Hospital
so far.
Deponent
Recipient : Ben Marshall
Verification
Verified on this 4th day of 2022 the contents of above said affidavit are true and correct
to the best of my knowledge and belief. Nothing material has been concealed therein.
AFFIDAVIT
I _________________________________
Sarika Jaiswal Hereby solemnly affirm and declare as under:
1. That my ________________________
SON is willing to donate his/her one kidney to
his/her(relation) _______________________________who
Ben Marshall is suffering from Kidney
disease.
2. I further state that I do not have any objection if my (relation)__________
_______________________is
Rajesh J. Jaiswal donating one kidney to ________________
Ben Marshall
___________________________________________.
3. I further state that this Affidavit is with intent for submission to the Hospital authority
that is going to Transplant a kidney to _______________________
Ben Marshall
4. I say that all that this stated above is true to best of my knowledge and belief.
Deponent.
Donor Near Relative
Sarika Jaiswal
DONOR INFORMATION
Photo with
signature
FATHER’S NAME: KAHID JAISWAL ADDRESS : 288 W, Al Ghadir P.O Box 149
SIGNATURE OF DONOR
WE SOLEMNLY AFFIRM THAT THE ABOVE DECISION HAS BEEN TAKEN WITHOUT UNDUE
PRESSURE INCLUDING INFLUENCE ON ALLUREMENT AND THAT ALL POSSIBLE
CONSEQUENCES AND OPTION OF ORGAN TRANSPLANTATION HAS BEEN EXPLAINED TO
US.
PHOTO WITH
SIGNATURE
SEX : M
BLOOD GROUP : O+
BLOOD GENOTYPE : AA
BROTHER’S NAME :
SIGNATURE OF RECIPIENT
WE SOLEMNLY AFFIRM THAT THE ABOVE DECISION HAS BEEN TAKEN WITHOUT UNDUE PRESSUR E
INCLUDING INFLUENCE OR A LLUREM ENT AND THAT ALL POSSIBLE CONSEQUENCES AND OPTION
OF ORGA N TRANSPLA NTATION HAS BEEN EXPLAINED TO US.
__________________________ __________________
4th October 2022
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) sign(s) on the Notary Register, as well.
FORM – 8
To be self attested
across the affixed To be self attested
photograph across the affixed
photograph
Ben Marshall
Whereas I _______________________________________ have been
Dr Clifford Wiston
advised by my doctor ________________________________ that I am suffering from
___________________________________________________________________
Kidney Failure
____________________________ may be benefited by transplantation of
and
Kidney
_______________________ into my body.
_________________________________ ______________________________________
Signature of the prospective donor Signature of prospective recipient