Donor Application

Your Name

Father's Name

Your Email

Your Phone Number

Complete Address

Blood Group

Gender
MaleFemaleOthers

Donor Age

Which organ do you want to donate? (Tick applicable boxes)

Heart
Lungs
Kidney
Liver
Pancreas

Please specify any other organ.(Optional)

Which tissue do you want to donate? (Tick applicable boxes)
N.B: The following tissues can be donated after brain stem death as well as cardiac death.

Corneas/Eyeballs
Skin
Bones
Heart Valves
Blood Vessels

Please specify any other tissue.(Optional)

Do you want to donate all Organs?
YesNo

Do you want to donate all Tissues?
YesNo

First Witness Name

First Witness Phone

First Witness Address

Relation with donor

Second Witness Name

Second Witness Phone

Second Witness Address

Relation with donor

In the presence of the above-mentioned witnesses, I hereby unequivocally authorize the removal of the mentioned organs and tissues from my body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutical purposes. Please tick on the box to submit your form.