Registration Form

The following information is intended to provide you with information on the process of donation. If you have any questions or would like further explanation on this section, please call Donor Network of Arizona at 800-94-DONOR (800-943-6667).

close consent description

I understand and authorize the following as indicated by my signature for consent at the end of this document:

Donation requires both a physician’s legal declaration of death and the decision to help others. There is no cost to the family or estate for anything related to the donation. All unrelated hospital charges as well as funeral expenses remain the responsibility of the family or estate.

The privacy and the confidentiality of the donor and the decision for donation will be respected. Information will be shared with those individuals and organizations involved in the donation process; this will include hospital and transplantation staff, the funeral provider and the medical examiner’s office. Copies of medical records, the death certificate and the autopsy report, if there is one, will be obtained and reviewed.

Part of the donor evaluation process requires transmissible disease testing. These tests are performed to ensure the safety of transplant recipients. Arizona laws requires that positive confirmed tests be reported to the Arizona Department of Health Services. Other evaluative tests, procedures and biopsies may also be performed. For organ donation, the recovery of the spleen and lymph nodes takes place to ensure the compatibility between the donor and transplant recipients. Blood vessels may also be recovered for the purpose of safe organ transplantation.

The placement of organs and tissues is directed by local, state and federal guidelines and transplantation standards. At times, tissue may be sent to help people in other countries. Through medical breakthroughs, recovered tissue can be reshaped and reformed to accommodate a variety of transplant needs. Also, in order to benefit the greatest number of recipients, both nonprofit and for-profit organizations may be involved in the process.

The work of recovery in the donation process is performed with care and does not normally interfere with funeral arrangements. Donation includes the careful restoration of the donor. Bruising and swelling are rare but can occur. For tissue donation, the donor may be transported to a donation facility for recovery procedures. The medical examiner’s office will determine if an evaluation or autopsy is necessary and if any restrictions regarding the donation process are required. Following the recovery of anatomical gifts and the medical examiner’s evaluation (if applicable), funeral plans and/or other arrangements may proceed.

Personal Details:
Fields marked with an asterisk (*) are required.
First name *  
Middle name
Last name *  
Street address *  
City *  
State *  
Zip *  
Phone (###-###-####)  
Gender *  
Date of birth * (mm/dd/yyyy)   
Country of birth *  
Mother's maiden name *  
Drivers license *  
E-mail address  
How'd you hear about us? *  
 

Please select the items you wish to donate:
Check "no" to any items that you DO NOT wish to donate. Click an item name for more detailed information about that item or items.
 Heart:  Heart (For Valves):
 Eyes:  Small Intestine:
 Kidneys:  Bone & Associated Tissue:
 Liver:  Veins & Arteries:
 Lungs:  Skin Tissue:
 Pancreas:  Pericardium:
 
 

Intended Purpose:         
I offer the donation of the above checked organs/tissue/eyes for the following purposes:

Transplant and Research
Transplant purposes only
 

Authentication:
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Password *      
Confirm Password *      
     
I agree that detailed information regarding my donation, from recovery through transplantation, has been made available to me through this registration. By submitting this registration I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a registration of my document of gift as outlined in the Arizona Uniform Anatomical Gift Act. A document of gift not revoked by the donor before death is irreversible and does not require the consent of any other person.