ORGAN AND TISSUE DONOR REGISTRATION FORM
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State Driver License #

_________    _____________________________________________


Social Security #

_______________________________________________


Date of Birth (ex. 01/15/2000)    

_____________________________     Sex:_____M _____F


Name __________________________________________________


Address ________________________________________________


City ________________________________________ State ______

Zip _______________________

Signature of Donor ___________________________________________

Date signed _______________

 In the hope that I may help others, I hereby make this organ and tissue gift, If medically acceptable, to take effect upon my death. The words and marks (or notations) below indicate my desires. Default choice is (a).
I give:
(a) ____ any needed organ or tissue
(b) ____ only the following organs or tissue for the purpose of transplantation, therapy, medical research or education:
_________________________________________________
(c) ____ my body for anatomical study if needed.

Limitations or special wishes, if any, list below:
_________________________________________________

NEAREST RELATIVE INFORMATION


Name ____________________________________________________

Address __________________________________________________

City _________________________ State ________ Zip ___________

Telephone # (________) _____________________________


WITNESS INFORMATION

Witness _________________________________________
Date signed _______________

Witness (Parent or Guardian if under 18) _____________________
Date signed _______________

This is a legal document under the Uniform Anatomical Gift Act or similar laws, Chapter 765, Part V Florida Statutes. For more information, visit the Agency for Health Care Administration on the web at http://ahca.myflorida.com.
Sponsored by Agency for Health Care Administration and Department of Highway Safety and Motor Vehicles
2727 Mahan Drive - MS 37 Tallahassee, FL 32308