Pledge your EYES

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

  1. Fill in the Donor Pledge Card below. (if you are not 18, have your parent or guardian as one witness).
  2. 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.
  3. mail your pledge form .
  4. We will send you in return a wallet card stating your pledge and instructing your next-of-kin or your wishes.
  5. 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

Comments

Submitted by pooja on Sat, 07/14/2007 - 12:56

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