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Organ (S) and Tissue (S) Donor Form

This document contains an organ/tissue donation pledge form for Jawahar Lal Institute of Post Graduate Medical Education & Research. The form allows an individual over 18 to pledge specific organs and tissues. The individual provides their name, age, address and contact details. They then select which organs and tissues they wish to donate from checkboxes listing options like heart, lungs, kidneys, liver, pancreas, corneas and more. The individual signs the form, and it is also signed by two witnesses. Notes on the form indicate organ donation is a family decision and the individual can withdraw the pledge.

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vaideeswari kumar
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48 views1 page

Organ (S) and Tissue (S) Donor Form

This document contains an organ/tissue donation pledge form for Jawahar Lal Institute of Post Graduate Medical Education & Research. The form allows an individual over 18 to pledge specific organs and tissues. The individual provides their name, age, address and contact details. They then select which organs and tissues they wish to donate from checkboxes listing options like heart, lungs, kidneys, liver, pancreas, corneas and more. The individual signs the form, and it is also signed by two witnesses. Notes on the form indicate organ donation is a family decision and the individual can withdraw the pledge.

Uploaded by

vaideeswari kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION & RESEARCH (JIPMER)

PUDUCHERRY-605006.Ph:0413-2272380,2272390
FORM 7
FOR ORGAN OR TISSUE PLEDGING
(To be filled by individual of age 18 year or above)
[Refer rule 5(4)(a)]
ORGAN(S) AND TISSUE(S) DONOR FORM
(To be filled in triplicate)

JIPMER/OD/2018/
Registration Number (To be allotted by Organ Donor Registry)…….………………..................................................................................................
I,………………………………………………..........................S/o,D/o,W/o..........................................................................................................
aged………………………and date of birth………………………….resident of ………………………….................................................................
in the presence of persons mentioned below hereby unequivocally authorize the removal of following organ(s) and/or tissue(s), from my 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


(Following organs can only be donated after brain stem death)
(Following tissues can also be donated after
brain stem death as well as cardiac death)

Heart Corneas/Eye Balls


Lungs Skin
Kidneys Bones
Liver Heart Valves
Pancreas Blood Vessels
Any other Tissue (Pl. specify) ……………
Any Other Organ (Pl. specify)…………… All Tissues
All Organs

My blood group is (if known)……………

Signature of Pledger..............................................

Address for correspondence………………............................................................................................................................................ ..........


Telephone No.……………………………………….

Email : ………………………………………………

Dated:.......................................................................

(Signature of Witness 1)
1. Shri/Smt./Km.…………………………………………S/o,D/o,W/o………………………..................…………aged………………..resident
of........................................................................................................................... ...........................Telephone No..............................................
Email:.............................................................................................................................................. ......................................................................

(Signature of Witness 2)
2. Shri/Smt./Km.…………………………………………S/o,D/o,W/o………………………………...........………aged……………….resident
of ………………………................................................................................... ............................. Telephone No..............................................
Email:............................................................................... is a near relative to the donor as ...............................................................................

Dated………………….
Place …………………..

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 to follow through with your wishes.

(ii) The person making the pledge has the option to withdraw the pledge.

(iii) In case of online registration, one copy of the dully filled form shall be retained and a second copy signed by pledger and two witnesses
shall be submitted to the office of the nodal officer,NOTTO, Department of Nephrology, JIPMER.

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