All India Institute of Medical Sciences

ORGAN RETRIEVAL BANKING ORGANIZATION (ORBO)

All India Institute of Medical Sciences

Ansari Nagar, New Delhi-110029

ORGAN(S) AND TISSUE(S) DONOR FORM

Enter the Category

Regn. No.

Date

* Name

Enter the Name

Gender

Male

Female

Organ Name

Tissues

(Tissues can also be donated after Brain Stem Death as well as Cardiac Death)

Blood Group

* Date of Birth

Enter The date of Birth

* Address

Enter the address

City

State

Email

* Mobile No

Enter the Mobile No

Choose Identity Proof

Enter Identity Card No

Emergency Contact No.

Details of witnesses

Witness 1

Name

Address

Mobile No

Witness 2

Name

Address

Mobile No

I uneqivocally authorise the removal of the above organ(s) and/or tissue(s), from my body after being declared brain stem dead by the board of medical expperts and consent to donate the same for therapeutic purposes.