Sotto Mizoram - Organ and Tissue Donation Form

ORGAN AND TISSUE DONATION FORM

PERSONAL INFORMATION

Name *

DOB *

Mobile Number *

Address *

Father's name / Spouse's name *

Blood Group *

Gender *

Male

Female

ADDRESS DETAILS

Address *

Pincode *

State *

District *

EMERGENCY CONTACT DETAIL

Name *

DOB *

Mobile Number *

Address *

Father's name / Spouse's name *

Blood Group *

Gender *

Male

Female

PLEDGE DETAILS

Choose the organs to pledge *

Kidney

(Following tissues can also be donated after brain stem death as well as cardiac death)

Choose the organs to pledge *

Kidney