Request And Permission For Post Mortem Examination
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2*15360*
Complete details or affix label
URN:
*
1
5
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6
0
*
Surname:
ACT Health
Given name:
Request and Permission for Post
Mortem Examination
DOB:
Gender:
I
hereby grant permission to the Pathology Department at
Canberra Hospital to perform a post mortem examination on the above named.
The Post Mortem procedure has been explained to me by Dr.
and I have been
provided with an information pamphlet about post mortem examinations.
1. I consent to the following being carried out on the above named deceased (please tick appropriate item
below)
A full post mortem examination, including examination of the brain, of the deceased OR
A limited post mortem examination of the deceased
[If limited permission given, state the part of body to be examined]
I understand that small samples of organ tissue and body fluids will be removed at the time of the post mortem
for microscopic examination and other pathology tests. These tissue samples will be retained indefinitely
according to legal requirements
2. I also consent to retention of organs by the pathologist for further detailed examination (please tick
appropriate item below)
Any Organ
The following specific organs may be retained:
I do not give permission for any organ to be retained
3. If consent to retention of organs is given I wish the retained organs to be disposed of as follows: (please tick
appropriate item below)
In a lawful manner by the hospital
Returned to the body prior to the funeral
Returned to me or a person nominated by me (phone no.)
4. For an adult post mortem only: If the pathologist considers an organ valuable for teaching purposes
(please tick item(s) below)
I have no objection to the retention of such organ(s)
I would like to be contacted by phone on
(phone no) to consider providing
permission for retention at that time
I do not give permission for any organ to be retained
Signed (senior available next of kin or patient)
Date:
/
/
Relationship to patient:
Witness:
(sign and print name)
Doctors Use Only
I confirm that I have explained the post mortem procedure and the reasons for the retention of body tissue(s) to
the person consenting:
Doctor's signature
Print name
Designation
Date
Hospital Use Only
As a Designated Officer, I authorise a post mortem examination and certify that as far as can be determined:
The deceased had during their life time expressed the wish for or agreed to a post mortem examination to investigate
the cause of death and not subsequently revoked this wish
The deceased had not in their lifetime expressed any objection to the post mortem examination of their body and
The senior available next of kin of the deceased (as above) has not objected to a post mortem examination or
There is no next of kin in existence or available
Designated Officer:
(Sign and print name)
15360(0714)
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