EYE DONOR REGISTRATION FORM

Fields marked * are Mandatory.

Name *
Guardian's Name
Age *
Sex	Male Female
Medical History *
Address *
Phone *
E-Mail *
Eye Bank Contact Number

TO WHOMSOEVER IT MAY CONCERN

I declare my desire for eye donation after my death. I have informed my kith and kin accordingly and there will be no Objection from them. Hence I sincerely request my close relatives, friends (or) well wishers to contact and call. People for MY VOLUNTARY EYE DONATION, AT THE EARLIEST.

I Agree