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PROJECTS -  EYE BANK - Eye donation form

Eye Donation Form

Donate your eyes...... NAYANA EYE BANK

 

 

I, ______________________________________________ son / daughter / wife of_________ _____________________________________________________ aged _________ years, residing at _____________________________________________ hereby express my free and frank consent for the removal of my eyes after my death from my body, by a registered medical practitioner (Ophthalmic) of a recognized Eye Bank / Hospital for their use for therapeutic purposes. I have been explained and I understand all the aspect of such a donation.

Place _____________________________ Signature ___________________________
Date ______________ Time ______ AM/PM

 

 

1. Witness (Next of kin)
Signature __________________________

Name ____________________________

Relationship _______________________

Address __________________________

Telephone No., if any ________________

2. Witness

Signature __________________________

Name ____________________________

Address __________________________

Telephone No., if any ________________

 

Name of the nearest hospital _________________________________________________

 

Name of the family physician, if any ____________________________________________

 

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for official use only


Donor Card No. _______________________

Dated _______________________________

 

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