Multi Organ Donation

During lifetime, a person can pledge for organ donation by filling up a donor form in the presence of two witnesses, one of who shall be a near relative.


Donor Registration Form

Name*
 
Mother's Name*
Age*
Sex*
Male Female
Organ*
All Organ Corneas(eyes) Kidneys
Heart Lungs Liver
Pancreas    
Address*
Phone*
Mobile*
Email*
My Next of Kin Contacts (Emergency Contact persons)
1 Name of Kin 2 Name of Kin
  Email of Kin   Email of Kin
  Contact of Kin   Contact of Kin
Name   Name
Parent Legal Guardian   Friends Relative
Address   Address
Comments
Data Protection Assurance: Completion of this form is for the purpose of recording your wishes to become an organ donor. We will ensure that the data will be protected by the Indian Act requirements.

1. After receiving the filled in form, we will provide the donor with an organ donor card bearing registration number on it.
2. It is suggested to keep the donor card in your pocket and share your decision with your near and dear ones.


Join Us

Say "yes" to Multi Organ Donation Carry a "Donor Card"
Click Here

Connect Us