Organ Donation Online Form
"
*
" indicates required fields
Name
*
First
Fathers/Spouse Name
Date of Birth(Only persons above 18 years are eligible)
*
Day
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Year
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Blood Group
*
A+
A-
B+
B-
O+
O-
AB+
AB-
Please tick as applicable
Organs to Pledge
*
Heart
kidney
Lungs
Liver
Pancreas
Intestinal Tract
Select All
Following tissues can also be donated after brain stem death as well as cardiac death
Corneas/Eye Balls Skin
Bones
Heart Valves
Blood
Vessells
Tissue
Select All
Are you willing to donate entire entire body after death
Entire Body(Entire body can be donated after death)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone/Mobile
*
Witness Name
Alternate Mobile Number for Reference or Witness
*
Email
*
Aadhar Card
Accepted file types: jpg, jpeg, png, gif.
Volunteer Photo
Accepted file types: jpg, jpeg, png, gif.
How do you came to know about organ donation
Social Media
Newspaper
Rotary Club
Friends
Referral
Others
Digital Signature
Consent
*
I agree to the privacy policy.
1. 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.
2.One copy of the pledge form/pledge card to be with respective networking organization, one copy to be retained by institution where the pledge is made and one copy to be handed over to the pledger.
3.The person making the pledge has the option to withdraw the pledge.
I am organ donar
Organ Donor ID card will be received shortly after submission of this form
Download ORGAN DONATION FORM