FORM 7 FOR ORGAN OR TISSUE PLEDGING
(To be filled by individual of age 18 year or above) [Refer rule 5(4)(a)]
ORGAN(S) AND TISSUE(S) DONOR FORM
(To be filed in triplicate)
I would like to donate my Organs/Tissue in the event of my death. I confirm I have had a discussion with my family.
FULL NAME *
FATHER NAME *
AGE *
DATE OF BIRTH *
MM
/
DD
/
YYYY
ADDRESS *
CITY
PINCODE
Email Address *
TELEPHONE or MOBILE NUMBER
BLOOD GROUP (IF KNOWN)
PLEASE TICK AS APPLICABLE
(FOLLOWING TISSUES CAN ALSO BE DONATED AFTER BRAIN STEM DEATH AS WELL AS CARDIAC DEATH)
Note
In case of online registration of pledge, one copy of the pledge will be retained by pledger, one by the institution where pledge is made and a hard copy signed by pledger and two witnesses shall be sent to the nodal networking organisation.
1) WITNESS FULL NAME *
FATHER NAME
AGE
ADDRESS
EMAIL *
TELEPHONE or MOBILE NUMBER *
2) WITNESS FULL NAME *
FATHER NAME
AGE
ADDRESS
EMAIL *
TELEPHONE or MOBILE NUMBER *
NOTE
(i) Organ donation is a family decision. Therefore, it is important that you discuss your decision with family members and loved ones so that it will be easier for them to follow through with your wishes.

(ii) One copy of the pledge form/pledge card to be with respective networking organisation, one copy to be retained by institution where the pledge is made and one copy to be handed over to the pledger.

(iii) The person making the pledge has the option to withdraw the pledge.
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