EYE BANK
(Authority of donor for removal of eyes)
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 form 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 aspects of such a donation.
Place………………………
Signature……………………….
Date ……………………………...
1.
Witness (next of kin)
Signature ……………………
Time ………………………… AM/PM
Name..…………………………….…………………………………………………………………
2.
Witness (next of kin)
Signature ……………………
Relationship …………………….…………………………………………………………………
Name..…………………………….…………………………………………………………………
Address ………………………….…………………………………………………………………
Tele: No. (if any) ……………….…………………………………………………………………
Name of the nearest Hospital
Stamp
Name of the family physician
If any
…………………………………….
For Official use
To
Eye Bank
________________________________
________________________________
Donor No…………………………………
Eye Bank
Certified that Sh/Smt/Kum………………………………………………………………………………
Has bequeathed his/her eyes, to the National Eye Bank, after death.
Date…………………………………
for Eye Bank
Eye Donor Pocket, CARD
Kindly inform the National Eye Bank Tele…………………………………………… Immediately
on my demise and help them to fulfill my last desire.
Thank you,
Signature of the Donor
Date……………………..