PLEDGE FORM FOR EYE DONATION


ROTARY EYE BANK
Sir Ganga Ram Hospital, New Delhi
Telephone No.: 25735205, 25851463 Extn.:1136, 1340
Mobile: 9811771213

I, hereby declare the wish to donate my eyes to the nation and enjoy upon one another that this wish be put into effect by inviting a doctor to remove both eyes upon death for therapeutic transplantation or medical research and education.

Donor Name:
Sex: Male Female
Age: yrs
Address:
Telephone:
Email:
Relative Name: Relative Name:
Relation: Relation:
Address:  Address:
 

Note-
(a) Inform the hospital immediately.
(b) Kindly ensure proper closure of the eye lids.
(c) Place some ice on the eye lids.