Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form (Page 8 of 9) in pdf

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 8

Uniform Donor Form

The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The

words and marks below indicate my desires:

I give:

(a) _____ any needed organs or parts

(b) _____ only the following organs or parts for the purpose of transplantation, therapy, medical

research, or education:

_____________________________________________________________

Signed by the donor and the following witnesses in the presence of each other:

Donor’s Signature ___________________________________ Donor’s Date of Birth _____________

Date Signed ______________ City and State _____________________________________________

Witness _____________________________

Street Address ________________________

City _____________________ State ______

You can use this form to indicate your choice to be an organ donor. Or you can designate it on your

driver’s license or state identification card (at your nearest driver’s license office).

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 8