To gain a chance to live forever, GIVE SOMEONE THE GIFT OF LIFE…

All individuals can indicate their intent to donate after death. Medical suitability for donation is determined at the time of death.

Most important, discuss with your family members and loved ones. If you sign a Donor Card, it is essential that your family knows your wishes. Your family may be asked to sign a consent form in order for your donation to occur.

Print or e-mail a family notification card now.

Indicate your intent to be an Organ Donor by filling the form below and we will send you your Organ Donor Card at your mailing address. Carry it with you

Full Name : *
Mailing Address :
Contact No : *
Email : *
Blood Group :
Date of Birth :
Any Disease   History :
The following family member knows of my wishes
Full Name : *
Relationship : *
Mailing Address :
Email : *
I request that after my death:   Any part of my body be used for treatment of others
	Kidneys
	Heart
	Liver
	Lungs
	Pancreas
	Eyes
	Skin