Regional Institute of Ophthalmology, Thiruvananthapuram

www.riotrivandrum.org phone: 0471-2304046

FAMILY PLEDGE FORM FOR EYE DONATION I/We hereby make this anatomical gift, if medically acceptable, to take effect upon my/our death we would like donating my/our eyes to Regional Institute of Ophthalmology or any authorized Eye Bank after my/our death for the purpose of transplantation, research and education. We would further take the responsibility of informing the Eye Bank of any death that we come to know and arrange for eye donation.
Relationship/witness Self Name in Block Letters Sex Date of Birth Signature

Address: Pin code: Telephone: District: State: Date: Place:

Kindly take a print out of the form, fill it carefully and make sure to send us a copy of it. Eye donation is free of cost Witness should be a blood relative

Regional Institute of Ophthalmology, Thiruvananthapuram

www.riotrivandrum.org phone: 0471-2304046
INDIVIDUAL PLEDGE FORM FOR EYE DONATION I hereby make this anatomical gift, if medically acceptable; to take effect upon my death I would like donating my eyes to Regional Institute of Ophthalmology or any authorized Eye Bank after my death for the purpose of transplantation, research and education. I would further take the responsibility of informing my relatives my wish and thus they would inform my death to the Eye Bank and arrange for eye donation.
Name in Block Letters Self Address: Sex Date of Birth Signature

Telephone: Witness 1 Name & Address: Signature Witness 2 Name& Address Signature Date: Place:

Kindly take a print out of the form, fill it carefully and make sure to send us a copy of it. Eye donation is free of cost Witness should be a blood relative