ORGAN PLEDGE FORM
This Form is in accordance with the Transplantation of Human Organs Act 1994.
Fields marked with
*
are mandatory.
First Name
*
Last Name
*
Father Name
Husband Name
Gender
*
Select
Female
Male
Blood Group
Select
A+
A-
AB+
AB-
B+
B-
O+
O-
Dont Know
Email
*
Address
*
City
*
Pin Code
State
*
Witness 1
Name
*
Relationship
*
Select
Aunt
Brother
Brother-in-law
Child
Cousin
Daughter-in-law
Father
Father-in-law
Mother
Mother-in-law
Nephew
Niece
Sister
Sister-in-law
Son-in-law
Spouse
Uncle
Other
Address
Contact Number
It is necessary for one of the witnesses to be a close family member.
Witness 2
Name
*
Relationship
*
Select
Aunt
Brother
Brother-in-law
Child
Cousin
Daughter-in-law
Father
Father-in-law
Mother
Mother
Mother-in-law
Nephew
Niece
Sister
Sister-in-law
Son-in-law
Spouse
Uncle
Other
Address
Contact Number
Organs/ Tissues to be pledged
*
All suitable organs
Bone Marrow
Eyes
Heart
Kidney
Liver
Lungs
Skin
Hold Ctrl. Key to select multiple options.
Terms & Conditions
I hereby unequivocally authorize the removal of my organ / organs, mentioned above from my body after my death for therapeutic purposes.
I hereby confirm that I am aware of the importance of having the witness signature on the Pledge card, and I take full responsibility for its implementation
I hereby confirm that all the above information is right and I choose to pledge my organs being in the sane state of mind.
I would like to receive the GYO Newsletter.
I accept terms & conditions
*
Verification Code
*
Please type the Verification Code as you see above.