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REGISTRATION FORM WHAT TISSUE WHO CAN BE A DONOR?

Please complete ALL fields in order to be entered onto the database CAN BE DONATED? Any healthy individual between the ages of 15
Date: ___________________________________________________ and 80 years may potentially donate tissue – at the
Title: Mr Mrs Ms Dr Prof. time of death the medical team will determine
Name: __________________________________________________ which tissue can be used in transplantation.
Surname: ________________________________________________
Email: ___________________________________________________
HOW MUCH DOES IT COST AND WILL IT DELAY
Postal Address: ___________________________________________
Heart valves FUNERAL ARRANGEMENTS?
________________________________________________________ Corneas
Donor heart There is no cost involved in the donation of
Postal code: ______________________________________________
The corneas valves (aortic tissue and neither is there any reward. Tissue
Landline Number: _________________________________________ can be used and pulmonary) is retrieved without compromising the funeral
Cell Number: _____________________________________________ to avert may be used to arrangements and does not interfere with burial
or correct correct or repair
ID Type: R.S.A. ID Passport blindness. cardiac defects and cremation plans.
or damage.
ID/Passport Number _______________________________________
Gender: Male Female
WILL THE DONOR BE TREATED WITH DIGNITY?
For research purposes please indicate your ethnic group:
Our professional retrieval teams are bound
Black White Coloured Indian Asian Other by very strict codes of conduct to ensure that
How did you hear about organ donation? ______________________ Skin each donor is treated with respect and dignity.
Written consent is required for all tissue
Would you like to receive news via email? Yes No The topmost layer
of skin (epidermis) retrieval. A prosthetic device is inserted in the
Next of kin information contact details over the age of 18
is carefully removed place of the removed tissue to ensure that there
Name: _________________________________________________ Bone and Tendons from the larger is no disfigurement of the donor’s body.
areas of the
Surname: _______________________________________________ Bone, cartilage and donor body which
tendon grafts can
Relationship to donor: _____________________________________ be used to help then provides a HOW CAN I MAKE A DIFFERENCE?
restore function lifesaving solution
Landline number: _________________________________________ for thousands of
and mobility • Discuss the possibility of tissue donation with
Cell Number: ____________________________________________ in people who critically burned the rest of your family and make sure that
patients every year.
would otherwise
E-mail: _________________________________________________ they understand that you would like to be a
be incapacitated
PLEASE RETURN THIS FORM: or disabled, and donor after your own death.
BY FAX TO (021) 426 0197 OR EMAIL – bongiwe@odf.org.za Or are used in the • Register today at: www.odf.org.za or
POST TO PO BOX 2349 CAPE TOWN 8000.
For more information contact our Toll Free Line – 0800 22 66 11 or visit our website treatment of a wide www.tissuedonation.org.za.
www.odf.org.za range of medical
TERMS and CONDITIONS conditions including • No medical tests are required for registration
By registering as an organ donor I understand and agree with the following: I’m reg- maxillofacial and and it is not necessary to complete any
istering as an organ donor by my own conviction. I understand that registering, as an orthopedic injury, additional forms. At the time of death, written
organ donor, is completely free of charge. I agree that my personal information may spinal surgery,
be stored on the database of the Organ Donor Foundation and be only used for the consent for donation will be requested from
advancement of organ donor awareness in general. I accept that the Organ Donor and treatment of
Foundation will secure and safeguard my personal information within the framework trauma injuries. the family.
of the South African Protection of Personal Information Act (POPI-2013). I agree to
inform my next of kin of my wish to be an organ donor. If I’m under the age of 18 I con-
firm that my parents or guardians are aware that I‘m registering as an organ donor.
I agree that medical professionals may have access to my personal information and
the information of my next of kin and that this information will only be used, if relevant,
for the purposes of my intention to be an organ donor.