Transplant Support Group

Donor Card Registration Form.

A Donor Card will be provided on the information given on this Form. Your particulars will be included in the I.T.U. Donors Register and will so remain unless you change your mind.

Full Name

Full Address

ID Card No

Date of Birth

E-mail

Tel. No

In the event of my death please inform

I declare and authorise that in the event of my death (Choose where applicable)

Any part of my body may be used for transplantation

Only the organ/s indicated may be used for transplantation

Kidneys	Heart	Lungs
Liver	Cornea	Pancreas

Please enlist my name in the Organ Donation Register so that, following my death, my organ/s can be used in the care of others

* required fields