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 Dr. Sanjay Dhawan
Pledge Form

There are millions of people who are blind because of problems affecting the cornea. They can regain good vision by corneal transplantation (so called eye transplant). But the rate of eye donations is far less than the need.

Therefore, it is an appeal to everyone to pledge to donate your eyes. One of the most noble deeds one can do.
 

National Eye Bank

(Authority by Donor for removal of eyes)

I, ____________________________________________son/daughter/wife of _____________________________________________ aged _________ years, residing at ________________________________________________________________________ hereby express my free and frank consent for the removal of my eyes after my death from my body, by a registered medical practitioner (Ophthalmic) of a recognized Eye Bank / Hospital for their use for therapeutic purposes. I have been explained and I understand all the aspect of such a donation.
 Place  Signature
 

Date ______________ Time ______  AM/PM
 1. Witness (Next of kin)  2. Witness

Signature __________________________

Name ____________________________

Relationship _______________________

Address __________________________

Telephone No., if any ________________

Signature __________________________

Name ____________________________

Address __________________________

Telephone No., if any ________________

 

Name of the nearest hospital _________________________________________________

Name of the family physician, if any ____________________________________________

For official use only:

Donor Card No. _______________________

Dated _______________________________

 
 
 
 
 
 
 
 
Author: Dr. Sanjay Dhawan
Last Updated on: 1 March, 2014
   

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