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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
AIIMS
CRPF
Regn. No.
D
*
Name
S/O
D/O
W/O
Gender
Male
Female
Organ Name
All/
Heart
Lungs
Kidneys
Liver
Pancreas
Intestine
Tissues
All /
Corneas/Eye Balls
Skin
Bones
Heart Valves
Blood Vessels
(Tissues can also be donated after Brain Stem Death as well as Cardiac Death)
Blood Group
-Select-
A +ve
A -ve
B +ve
B -ve
O +ve
O -ve
AB -ve
AB +ve
Special Blood Group
*
Date of Birth
*
Address
City
State
–Select–
ANDAMAN AND NICOBAR ISLAND
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATISGARH
DADRA AND NAGAR HAVELI
DAMAN AND DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU AND KASHMIR
JHARKHAND
LAKSHADWEEP
MAHARASHTRA
MANIPUR
MIZORAM
NAGALAND
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TRIPURA
UTTAR PRADESH
WEST BENGAL
Unknown
KERALA
KARNATAKA
MADHYA PRADESH
MEGHALAYA
UTTRAKHAND
Other
Telangana
Email
*
Mobile No
Choose Identity Proof
-Select-
Driving Liscence
Adhar Card
Voter ID Card
Pan Card
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.
For Further Information Click Here
www.orbo.org.in
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