DR. RAJKUMAR EYE BANK # NARAYANA 1204 .chord Road al Nagar, Block. angle 560010 NETHRALAYA ‘Tel: +91-9741685555, +91-9902546046, +91-8066121400-1404 Y pcueseateal |:info@narayananethralaya.com, info@nnmail.or¢ supe Spat Ee Hog Emalinfognarayananethralaya.com,info@nnmail org Post Graduate neti fOphhamony wn narayananethralayaorg UNIFORM DONOR PLEDGE Date of Donation : Mr/Ms.: a Email ID... (Name of the donor) (Name of the next-of-kin) ‘Address of the donor: Addres (City, State, Pin Code) ... Phone: Blood Group: Witness Address: Phot INSTRUCTIONS: 1. Fillin the Donors Pledge Card. Have your signature witnessed witnessed by two persons. (Ifyou are not 18, have your parents of guardian as one witness). 2. Discuss your decision with your nextof-kin and your family doctor. We will inform your next-of-kin of your pledge. 3. Mail the complete pledge card to: Dr. Rajkumar Eye Bank Narayana Nethralaya-1 121/C, Chord Road, Rajaji Nagar, 1st'R’ Block, Bangalore - 560010 Te: +91-9741685555, +91-9902546046, +91-8066121400-1404 4, Weill send you retum a wallet card stating your pledge and instructing your next-of-kin your wishes. 5. Please carry wallet card stating you atall times. If you change your name or address, please inform Dr. Rajkumar Eye Bank. E-mail: info@nnmall.org, info@narayananethralaya.com et aade\ le kee SMS Le PEL ed2 NARAYANA DR. RAJKUMAR EYE BANK NETHRALAYA T2VC Chord Road, Rajaji Nagar, 1st'®’ Block, Bangalore - 560 010 4h sa hel you — Tel: +91-9741685555, +91-9902546046, +91-8066121400-1404 Supe Specialy Eye Hoag E-mail: infoenarayananethralaya.com, infoennmailorg Post Graduate notin fOphharony ‘wmwenarayananethralaya.org FAMILY EYE PLEDGE In the hope that we may help others, we hereby make this anatomical gift of eyes effective after my / our death for Transplantation, Research & Education SINo. Name in Block Letters Age | Sex Relationship __| Signature 1 2 3. 4. 5. Witness: Head of the Family: Name: Name: Addres Address: Signature: Pea 1. Byes can be donated only after death. Eyes are too precious tobe buried or burnt. 2. Eyes can be collected at Hospital, Residence, Mortuary orat the place of death. An estimated 30 lakhs comeal blindare waiting for somebody todonate eyes. 3. One pair of eyes can give vision totwo corneal blind individuals. 4, Eyes should be donated withiné hours after death. 5, Removal ofeyes takes only 20 minutes and does notdisfigure the face. 6. Eyes are collected /distributed free of cost. 7. Our enucleating team willreach the place of diseased within30-40minutes. 8 — Wecollect eyes onlyin Bangalore city Metropolitan limits. 9. Our eye bank works 24 hours all through 365 days. 10. ifyoucome across death, please appeal tothe bereaved family and gently explain and motivate family todonate eyes. Call the eye bank tosend a Grief Counselor tomotivate the family. WHEN YOU COME ACROSS DEATH PLEASE 1. Close the eyes. 3. Puta polythene cover withfew ice cubes on forehead. 2. Raise the head withpillowand putoffthe fan, 4. Inform toDr. Rajkumar Eye Bank immediately. FOR EYE DONATION CONTACT: / +91 9902 546046