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Organ Donation Pledge Form
Personal Details
Full Name
*
Full Name *
Date of Birth
*
Date of Birth *
Gender
*
Gender *
Mobile Number
*
Mobile Number *
Address Details
*
Address Details *
Pledge Details
Blood Group
Blood Group
Email Id
Email Id
Organs
All Organs
Liver
Kidney
Heart
Lungs
Intestine
Pancreas
Tissues
All Tissues
Bone
Heart Valve
Skin
Cornea
Cartilage
Blood Vessels
Name of Individual/NGO/ Institution who motivated you to pledge
NGO
Enter NGO
Enter NGO
Emergency Contact Details
Name
*
Name *
Mobile Number
*
Mobile Number *
Relation
*
Relation *
Members to be Notified
Same as emergency contact
Name
*
Name *
Mobile Number
*
Mobile Number *
Relation
*
Relation *
I, hereby unequivocally authorize the removal of the above mentioned Organ(s) and/or Tissue(s) from my body for therapeutic purpose after being declared (Brain Stem/Cardiac) dead by the board of medical experts*
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 follow through with your wishes. (ii) The person making the pledge has the option to withdraw the pledge.
Submit Application
