gift a life

Call us Today : 011-29871777

Registration Form

My name and address

Name *
Date of birth *
Gender *
Male     Female
Blood Group *
Address *
Postcode *
Mobile *
Email Address *

My Wishes

I want to donate: (Please tick the boxes that apply)

A. Any of my organs and tissue
    or
B. My
Corneas Kidneys Heart Lungs Liver Pancreas Small bowel Eyes Tissue
for transplantation after my death.
Please tick here if you would like to receive future information about blood, organ and tissue donation from Gift a Life

My Next of Kin Contact

Name of kin:
Email of Kin:
Contact No:
Enter below security code *
          * fields are mandatory.

Data Protection Assurance. Completion of this form is for the purpose of recording your wishes to become an organ donor. All information provided to Gift A Life Organization is private. We will ensure that the data will be protected by the Indian Act requirements.