Organ Donor Registration Form

Specialty: General Practitioner **Organ Donor Registration Form** **Patient Information:** * **Name:** Mr. John Smith * **Date of Birth:** 15/03/1978 * **NHS Number:** 123 456 7890 * **Address:** 10 Downing Street, London, SW1A 2AA * **Contact Number:** 07700 900300 * **Email:** john.smith@example.com **Decision to Donate:** I, Mr. John Smith, hereby confirm my decision to register as an organ donor. **Organs/Tissues to Donate:** I wish to donate all organs and tissues suitable for transplantation. * Kidneys * Liver * Heart * Lungs * Pancreas * Small Bowel * Corneas * Skin * Bone * Tendons * Heart Valves **Consent for Research/Training (if organs/tissues cannot be used for transplantation):** I consent to my organs and tissues being used for medical research and training purposes if they cannot be used for transplantation. **Next of Kin/Family Information (for notification and discussion, if applicable):** * **Name:** Mrs. Jane Smith * **Relationship:** Wife * **Contact Number:** 07700 900301 **Declaration:** I understand that my decision will be recorded on the NHS Organ Donor Register. I confirm that I am over 18 years of age and capable of making this decision. I understand that my family will be involved in the final decision-making process at the time of my death. **Patient Signature:** John Smith **Date:** 1 November 2024 **Witness Information:** * **Name:** Dr. Emily White * **Profession:** General Practitioner * **Signature:** Emily White * **Date:** 1 November 2024