Donate Organs - Save Lives
For Organs/Tissue Pledging
(To be Filled by individual of age 18 years or above)
Full Name *
Your answer
Date Of Birth
MM
/
DD
/
YYYY
Address
Your answer
In the presence of person mention below hereby equicvocally authorise the removal of following organ(s)d/or tissue(s), from body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes.
Organ(s)
Tissues(s)
(Tissues can also be donated after Brain Stem Death as well as Cardiac Death)
My Blood group is (if known)
Your answer
Telephone number *
Your answer
Email ID
Your answer
Name Of Relative
Full Name *
Your answer
Date Of Birth
MM
/
DD
/
YYYY
Address
Your answer
Telephone number *
Your answer
Email ID
Your answer
is a near relative to the donor as:
Your answer
Note:
1. Organ Donation is a family decision. So 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.
2. The person making the pledge has the option to withdraw the pledge.
3. After filling the form, Kindly send it to Donate Life, on address mentioned below.
"Donate Life"
Opp. IDBI Bank, Nr. Kasanagar, Katargam, Surat-395004, Gujarat, India. Phone No.:+91-75730 11101/03/06/07
gmail: info@donatelife.org.in
site: www.donatelife.org.in
Toll Free Number: 1800 233 1944
"जीते जी रक्तदान, ब्रेनडेड के बाद किडनी, लिवर, ह्रदयदान..."
A Sample Donor Card
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