ROTTO Office, GMCH Complex, Near RIO (Regional Institute of Opthalmology) Gauhati Medical College & Hospital, Pin: 781032 ORGAN(S) AND TISSUES(S) DONOR FORM Enter the Category:GMCH Regn No: Your Name: S/OD/OW/OF/OM/O: Gender:MaleFemale Organ Name:AllHeartLungsKidneysLiverPancreasIntestine Tissues:AllCorneas/Eye BallsSkinBonesHeart ValvesBlood Vessels (Tissues can also be donated after the Brain Stem Death as well as Cardiac Death Blood Group:SelectA RhD positive (A+)A RhD negative (A-)B RhD positive (B+)B RhD negative (B-)O RhD positive (O+)O RhD negative (O-)AB RhD positive (AB+)AB RhD negative (AB-) Date of Birth: City: State:Select StatesAndhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest BengalUnion TerritoriesAndaman and Nicobar IslandsChandigarhDadra and Nagar Haveli andDaman & DiuThe Government of NCT of DelhiJammu & KashmirLadakhLakshadweepPuducherry Email: Mobile No: Choose Identity Proof:SelectDriving LicenseAadhar CardVoter ID CardPan Card Enter Identity card No: Emergency Contact No: Details of witness Witness 1 Name: Address: Mobile No: Witness 2 Name: Address: Mobile No: I uneqivocally authorise the removal of the above organs and/or tissue from my body after being declared brain stem death by the board of medical experts and consent to donate the same for therapeutic purposes. We will contact you soon.