An initiative for organ donation

Become a Organ Donor

Personal Information





Gender*

In the presence of person mention below hereby equivocally authorise the removal of following organ(s)d/or tissue(s), from the body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes.


Please Tick as Applicable

Organ(s):
Tissues(s):
(Tissues can also be donated after Brain Stem Death as well as Cardiac Death)



Name of Relative

Gender*

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 mention below.

"Donate Life"



Opp. IDBI Bank, Nr. Kasanagar, Katargam, Surat-395004, Gujarat, India.
Phone No: +91-7573011101/03/06/07
gmail: info@donatelife.org.in
site: www.donatelife.org.in
Toll Free Number: 1800 200 1944


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