Eye Care Delhi, India

For Appointments & Information: Call +91-9540009144/+91-9910009144 or E-mail : info@sdhawan.com

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	Eye Donation
	Pledge Form
	Eye Banks

National Eye Bank

(Authority by Donor for removal of eyes)

I, ____________________________________________son/daughter/wife of _____________________________________________ aged _________ years, residing at ________________________________________________________________________ hereby express my free and frank consent for the removal of my eyes after my death from my body, by a registered medical practitioner (Ophthalmic) of a recognized Eye Bank / Hospital for their use for therapeutic purposes. I have been explained and I understand all the aspect of such a donation.

Place

Signature

Date ______________ Time ______ AM/PM

1. Witness (Next of kin)

2. Witness

Signature __________________________

Name ____________________________

Relationship _______________________

Address __________________________

Telephone No., if any ________________

Signature __________________________

Name ____________________________

Address __________________________

Telephone No., if any ________________

Name of the nearest hospital _________________________________________________

Name of the family physician, if any ____________________________________________

For official use only:

Donor Card No. _______________________

Dated _______________________________

*The information given here is for public interest. Please do not send us this form. Also note that it is not essential to pledge to
donate the eyes.

Author: Sanjay Dhawan, New Delhi, India
Last updated on 16 November 2011

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Dr. Sanjay Dhawan, MBBS, MS (Gold Medalist), DO - Medical Director & Senior Eye Surgeon Phone: +91-9810009144
Appointment by phone: +91-9540009144/+91-9910009144OR call Helpline (+91) 9910009144 for any assistance.
Appointment by E-mail: info@sdhawan.com

Available at:
Vasan Eye Care Hospitals
Monday to Saturday 4.30 pm to 7.30 pmat S-341, Panchsheel Park, New Delhi 110 017
Monday to Saturday 9.00 am to 1.00 pm at No.36-B, Parvtesh Tower, Pusa Road, Opposite Metro Pillar No. 125 Karol Bagh, New Delhi - 110 060

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