Note: Fields marked * are mandatory

    I

    Age*

    agree to PLEDGE my SKIN, by Donating my SKIN after my DeathI grant permission for the recovery of my SKIN for purposes of Transplantation and Research.

    I would also like to donate my eyes

    YesNo

    Telephone

    Mobile No.*

    Address*

    Email of Donor*

    Family Doctor's Name

    Family Doctor's Telephone

    Next of Kin (The next of kin should be above the age of 18)

    Name*

    Email-Id*

    Address*

    Telephone

    Mobile*

    Once you are registered for SKIN DONATION, We shall send you Skin Donor Card, Magnetic Sticker and Skin Donor Badge.