Organ Donor Card

Organ Donor Card

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This is your UNIFORM DONOR CARD.
Here's all you have to do...
1. Designate your wishes by filling out the card, and sign it in front of two witnesses
2. Discuss your wishes with your family and give them the top half of the card
3. Carry the bottom half of the card (folded in half) in your wallet
4. Tell someone else about the Organ Donor Program

Give this portion of the card to your family.
This is to inform you that, should the occasion ever arise, I would like to be an organ and tissue donor. Please see that my wishes are carried out by informing attending medical personnel that I have indicated my wishes to become a donor. Thank you.
_____________________________ Signature

Signed by the donor and the following two witnesses in the presence of each other:
_____________________________ __________
Signature of donor                              Donor DOB
_________________      ____________________
Date signed                     City and state
_________________      ____________________
Witness                           Witness
This is a legal document under the Anatomical Gift Act or similar laws.
Yes, I have discussed my wishes with my family.

DONOR CARD Of _________________________
(Print or type name of donor)
In the hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and marks indicate my wishes. I give:
any needed organs or parts
only the following organs or parts
__________________________ (Please specify)
for purposes of transplantation, therapy, medical research or education;
my body for anatomical study if needed
Limitations/ special wishes: _________________

ORGAN DONATION
THE GIFT OF LIFE

MORE INFORMATION
Write or call: National Kidney Foundation of Southern California
15490 Ventura Blvd. Suite 210
Sherman Oaks, CA 91403
818.783.8153 | 800.747.5527