Organ Donation Registration Form
Organ Donation Registration Form
This form is designed to facilitate the registration of individuals interested in organ donation. Please complete all sections of this form accurately and thoughtfully.
Member Profile
Name
Date of Birth
Age
Phone number
Address
Organ Donation Details
Which organs or tissues are you willing to donate?
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Heart
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Lungs
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Kidneys
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Liver
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Pancreas
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Corneas
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Would you like to donate during your lifetime or after death?
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During my lifetime
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After death
Are you donating to a specific individual?
Reason for donation
Please specify the reason for donation.
Medical Information
Have you ever had any serious medical conditions?
If yes, please specify:
Are you currently taking any medications?
If yes, please list down:
Have you ever undergone any major surgeries?
If yes, please indicate:
Have you ever tested positive for infectious diseases (e.g., HIV, Hepatitis)?
If yes, please specify:
List allergies, if any:
Terms and Conditions
By signing this form, I acknowledge and agree to the following terms and conditions:
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I understand that my decision to become an organ donor is voluntary.
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I have provided accurate information to the best of my knowledge.
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I may withdraw my consent at any time by contacting [Your Company Name].
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I consent to the processing of my information in accordance with applicable laws.
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I understand that organ donation may involve medical procedures and the associated risks.
Name:
Date:
Thank you for considering organ donation. If you have any questions or concerns, please contact [Your Company Email].
