Enrollment Form - New York State Department Of Health
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1NYS Donate Life Organ and Tissue Donor Registry Specification Form
Please Print
( * required )
Prefix:
___________ (Dr., Fr., etc)
*First Name: ______________________________________________________
Middle Init: __________
*Last Name: _______________________________________________________
Suffix:
____________ (Jr, Sr, II, etc)
*Address: _________________________________________________________
__________________________________________________________
*City:
__________________________ *State: ________ *Zip: _________
Phone: (_____) ______ - _________
*Date of Birth: _____/_____/_____
*Gender: _____Male______Female
*Height: _____feet_______inches
*Eye Color: __________________
9- digit Motor Vehicle license or
non-driver license DMV issued ID number:
___________________________
* I offer the donation of:
All Organs, Tissues and Eyes
Limited Organs, Tissues and Eyes as specified below
Please CHECK the box of the organs and tissues that YOU WISH TO DONATE:
Bone and Connective Tissue
Liver/Iliac Vessels
Corneas
Lungs
Eyes
Pancreas (with Iliac Vessel)
Heart (For Valves)
Skin
Heart with Connective Tissue
Small Intestine
Kidneys
Veins
* I wish to donate the organs and or tissues specified above for:
Transplantation and Research
Transplantation only
Research only
I wish to enroll in the New York State Donate Life Organ and Tissue Donor Registry maintained by the State Department of
Health. I understand that by enrolling in the registry I am giving legal consent to the donation of my organs tissues and eyes (as
specified above) in the event of my death. I authorize the State Department of Health to access this information as needed in
administration of the registry, and to share this information at or near the time of my death with federally regulated organ
procurement organizations, New York State licensed tissue and eye banks and entities formally approved by the Commissioner.
________________________________________________________________
_____/_____/_____
Signature
Date
Mail to:
New York State Donate Life Organ and Tissue Donor Registry
New York State Department of Health
875 Central Avenue
Albany, NY 12206
Mod
Empire State Plaza, Corning Tower, Albany, NY 12237│health.ny.gov
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