Designation Of Health Care Surrogate Template Page 2

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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:
any needed organs or parts
only the following organs or parts for the purpose of transplantation, therapy, medical
research, or education:
my body for anatomical study if needed. Limitations or special wishes, if any:
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
Street Address
Street Address
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).


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