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Borang Pendaftaran Pendermaan Organ Nasional

Jadilah Pengikrar Pendermaan Organ Dan Tisu

Dengan Mengisi Maklumat Di Bawah

1. MAKLUMAT PERIBADI ANDA

Nama
K/P Lama
K/P Baru
Tarikh Lahir
Bangsa
Jantina
Alamat

No. Tel
Emel

2. WARIS

Nama
Hubungan

3. LANGKAH SETERUSNYA

Anda perlu memberitahu pihak keluarga mengenai keputusan anda untuk mendermakan organdan tisu
selepas kematian.

4. HASRAT ANDA

Saya berharap dapat mendermakan :-

a. Semua organ dan tisu
b. Atau Buah pinggang Hati Mata Kulit
Jantung Paru-paru Tulang

Untuk tujuan transplantasi.

Tandatangan Tarikh

TERIMA KASIH

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