Fillable Australian Organ Donor Register printable pdf download

Australian Organ Donor Register

New registration, change or removal

of donation decision details

Purpose of this form

Your date of birth

Complete this form to register, change or remove your donation

Your sex

Male

Female

decision details on the Australian Organ Donor Register (the Donor

Permanent postal address

People 16 years of age or older can register their donation decision

Where your organ donor registration is linked to your

on the Donor Register.

Medicare record, this address will be used to update the

Medicare record for everyone on your Medicare card.

For more information

For more information about the Donor Register, go to our website

www.

humanservices.gov.au/organdonor or call 1800 777 203.

Note: Call charges apply from mobile phones.

Postcode

Filling in this form

(

)

Daytime phone number

•

Please use black or blue pen

•

Print in BLOCK LETTERS

✓

•

Mark boxes like this

with a

Returning your form

This form can be returned to one of our Service Centres, or send

Organ and tissue donation

reply paid to:

I wish to register my consent to donate the following organs

Department of Human Services

and/or tissues for transplantation, in the event of my death.

Australian Organ Donor Register

(Tick ‘All’ or as many as apply):

Reply Paid 711

All

Bone tissue

Eye tissue

Heart

HOBART TAS 7001

Heart valves

Kidneys

Liver

or fax: 1300 587 189

Lungs

Pancreas

Skin tissue

Your decision

Privacy notice

Tick ONE only

I want to:

Your personal information is protected by law, including the

Privacy Act 1988, and is collected by the Australian Government

Department of Human Services for the assessment and

change my donation decision

administration of payments and services. This information is

details on the Donor Register

required to process your application or claim.

be removed from the Donor Register

Your information may be used by the department or given to

other parties for the purposes of research, investigation or

where you have agreed or it is required or authorised by law.

Your details

You can get more information about the way in which the

I authorise my donor registration to be linked to my Medicare

Department of Human Services will manage your personal

record

information, including our privacy policy at

humanservices.gov.au/privacy or by requesting a copy from

Medicare card number

www.

the department.

Ref no.

Declaration

Tick to authorise if Medicare card

number not known/available

Please register me, change or remove my details on the

Australian Organ Donor Register.

Donor registration number (if known)

•

I give permission for the details I have provided to be

actioned on the Donor Register.

•

I have discussed this decision with my family, partner or

Mrs

Miss

Other

friend.

•

I am aware that I can change my donation decision details

Family name

at any time.

Signature

First given name

Date

1 of 1

NH007DF.1502 (formerly 1397DF)

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Australian Organ Donor Register

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