Transplant authority Of Tamil Nadu

ORGAN DONATION PLEDGE FORM

Name *
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Date of Birth *
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Blood Group *
Organs
Government Id.No
Email
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District

Details of the person to be contacted in an emergency


Emergence Contact Name *
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Emergence Contact Address *
Emergence Contact Name 2 *
Emergence Contact Mobile *
Emergence Contact Address *
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I hereby declare that i am willing to donate my organs for social benefit as a life saving measure for a patients suffering from permanaent organ(s) failure,in the event of an unanticipated Brain Stem Death Occurring to me.

Date :

Transplant Authority Government Of Tamil Nadu

Transtan, 1045/46, 1st Floor, Tamil Nadu Government Multi Super Specialty Hospital, Omandurar Government Estate, Opposite to The Hindu Office, Anna Salai, Chennai 600 002
Tel / Fax : 044-25333676,   Email : organstransplant@gmail.com

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