Healthcare Donor Consent Form

Healthcare Donor Consent Form

Patient / Donor Information

Insurance Information

Donation Designation

I hereby consent to donation of the following (check all that apply):

Medical History (relevant to donation)

Consent, Authorizations and Certifications

I, the undersigned donor, certify that I am at least 18 years of age or am the legal representative of the donor and have authority to make this decision. I voluntarily authorize the procurement, removal and disposition of the body part(s) and/or tissue(s) indicated above for purposes of transplantation, therapy, research, education or scientific study, and I consent to any medical examination, testing and treatment reasonably necessary to accomplish such procurement.

I acknowledge that I have been informed of the nature of the donation and the reasonably foreseeable risks associated with the donation and related procedures, including but not limited to infection, bleeding, pain, scarring, anesthesia complications, organ dysfunction and, in rare cases, death. I understand the potential benefits may include therapeutic benefit to recipients or advancement of medical knowledge, and that no guarantee of benefit to any recipient or to me is made.

I understand that no payment or valuable consideration will be provided in exchange for the donation, except for reasonable reimbursement of direct expenses where permitted by law. I further authorize release of my relevant medical information to procurement organizations, tissue banks, hospitals and licensed professionals for the purpose of evaluating suitability for donation, administering the donation process and for follow‑up. I release and hold harmless all persons and entities involved in the procurement, transportation, storage, processing and transplantation of donated material from liability arising from customary and accepted procedures, except for gross negligence or willful misconduct.

I understand that this authorization permits the use and disclosure of my protected health information as necessary for procurement and transplantation purposes and that such information may be recorded and retained by procurement organizations. I acknowledge that reasonable efforts will be made to protect confidentiality consistent with applicable law, but once tissues or organs are released they may be used for transplantation, research or education as permitted by applicable law and policy.

I understand that I may revoke this consent at any time by providing written notice to the institution or procurement organization identified on this form, except to the extent that actions have already been taken in reliance on this consent. Revocation will not affect any actions taken prior to receipt of the written revocation.

By signing below I attest that I have read and understand this Healthcare Donor Consent Form, that the information I have provided is true to the best of my knowledge, that I have had an opportunity to ask questions and that my questions have been answered to my satisfaction. I understand that procurement personnel may be present during any relevant procedures and that representative(s) of procurement organizations may be informed of my medical history as necessary.

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