NIO - National Institute of Ophthalmology

Pledge Your Eyes

Requisition form for Eye Donation After Death

To,

The I/C Eye Bank

Dear Sir,

I hereby declare that I wish to donate my eyes after death so that they could be used for transplantation to restore Sight in blind persons or for research purposes for blindness prevention work.

Name
Age
Adress
Signature
Date
Phone
Witness
1. Nearest Relative
Name
Address
Signature
Date
Phone
1. Family Physician or Friend
Name
Address
Signature
Date
Phone