PLEDGE YOUR EYES DR. RAJKUMAR EYE BANK NARAYANA NETHRALAYA 121/C, Chord Road Rajajinagar, Ist 'R' Block Bangalore-560 010 Tel: 23373311, 23576855, 23577355 instructions for filling the donor card
- Fill in the Donor Pledge Card below. (if you are not 18, have your parent or guardian as one witness).
- Discuss your decision with your next-of-kin and your family doctor. We will inform your next-of-kin of your pledge, if you wish.
- mail your pledge form .
- We will send you in return a wallet card stating your pledge and instructing your next-of-kin or your wishes.
- Please carry the wallet card with you a all times. If you change your name or address, please inform Dr. Rajkumar Eye Bank.
UNIFORM DONOR PLEDGE In the hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and the marks below indicate my desire. I give my eyes for the purpose of transplantation, medical research or education. I further direct my next-of-kin herein to execute this gift after my death. I would like my next-of-kin notified of my pledge to donate.
SAMPLE OF DONOR CARD
* Name Of Donor
* Address Of the Donor
* Ph. No. Of Donor
* Blood Group Of Donor