Organ Donor Register - Registration, Change Or Removal Of Details printable pdf download

New registration, change or removal of details

Important information

Your sex

Complete this form to register, change or remove details from the

Male

Australian Organ Donor Register (the Donor Register).

Female

Only people aged 18 years and over can register their legally valid

Postal address

consent or objection on the Donor Register. If you are 16 or 17 you can

still register your intention to donate.

When your new registration is processed, a confirmation letter will be

sent to your permanent postal address.

Postcode

Assistance

Is this your permanent postal address?

If you need assistance completing this form call 1800 777 203 (call

charges may apply). For more information about the Donor Register go

Yes

Medicare Australia records will be updated to reflect this.

Daytime phone number

Lodgement

This form can be lodged:

(

)

in your local Medicare office,

or send reply paid to:

Australian Organ Donor Register

Reply paid 711

HOBART TAS 7001

or fax to: 03 6281 0556

Organ and tissue donation

Print in BLOCK LETTERS

I wish to register my consent to donate the following organs and/

Tick where applicable ✓

or tissue for transplantation, in the event of my death. Tick ‘All’ or

Registration details

as many as apply:

All

(tick one box only):

I want to

Bone tissue

Eye tissue

Heart

Heart valves

Kidneys

Liver

change my details on the Donor Register

remove me from the Donor Register

Lungs

Pancreas

Skin tissue

Declaration

Donor registration number (if known)

–

Please register me on, change my details, or remove my details

from the Donor Register.

Medicare card number

•

I give permission for the details I have provided to be actioned

Ref no.

on the Donor Register

If the Medicare card number is not known/available, I authorise

•

I have discussed this decision with my family, partner or

Medicare Australia to link the below details to my

friend

Medicare record.

•

I am aware that I can change these details at any time.

Applicant’s details

Signature

Date

Mrs

Miss

Other

Family name

Privacy note

The information on this form will be used to register you on the

First given name

Australian Organ Donor Register or to update your details on the

Medicare Australia Act 1973. This information may be disclosed to

Date of birth

authorised personnel in the organ and tissue donation network or

where authorised or required by law.

Page 1 of 1

2069 Code MURRAY 15.04.10

Organ Donor Register - Registration, Change Or Removal Of Details

Related Articles

Related forms

Related Categories