Donor Designation Disclosure
__________________________ has authorized the donation of his/her organs and tissues as evidenced by the
following legal document:
 Online Registry
 DMV Registry
 Other (specify): _________________
 A copy of the documentation of Donor Designation must accompany this form.
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This designation is the basis upon which the donation agencies (Pacific Northwest Transplant Bank,
Community Tissue Services, and Lions Eye Bank), in accordance with applicable laws as well as medical
and ethical standards, assume the care of his/her body for the purpose of removal and transplant of
organs, tissues and eyes.
The primary goal for organ, tissue and eye donation is transplantation. Unless restricted by the Donor
Designation, organs, tissues and eyes may be used for research.
The donation programs will cover any charges directly associated with the donation.
Funeral and burial arrangements remain the responsibility of the next-of-kin. Donation should not affect
funeral options and the donation agencies make every effort to minimize any delay in funeral
arrangements.
Examinations and procedures will be necessary to determine the medical suitability of the organs and
tissues for the purposes intended including, but not limited to, clinical imaging and testing for infectious
diseases.
Medical information necessary to determine the medical suitability of the organs and/or tissues for
transplantation will be reviewed and may be released to others as authorized by law or regulations.
 Copy offered to family
• Information disclosed by:
• Information disclosed to:
____________________________________
Donor Program Representative
___________________________
Print Name
____________________________________
Signature of Donor Program Representative
_____________________________________________
Address
______________
Date
_____________________________________________
City
State
Zip
______________
Time
_______________
Relationship
Revised 05/01/2008