Note: Fields marked * are mandatory

I
agree to PLEDGE my SKIN, by Donating my SKIN after my Death. I grant permission for the recovery of my SKIN for purposes of Transplantation and Research.
I would also like to donate my eyes
YesNo
Age*
Address*
Telephone
Mobile No.*
Email of Donor*
Family Doctor's Name
Family Doctor's Telephone
Next of Kin
Name*
Address*
Email-Id
Telephone
Mobile*

(*The next of kin should be above the age of 18)

Once you are registered for Skin Donation, We shall send you Skin Donor Card, Magnetic Sticker and Skin Donor Badge.