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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.

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Dr. Sanjay Dhawan, MBBS, MS (Gold Medalist), DO - Head of Department & Senior Eye Surgeon
Appointment by phone: (+91-11) 66114545, 26525555, 26499880 OR call Helpline (+91) 9910009144 for any assistance.
Appointment by E-mail: info@sdhawan.com

Consultation Timings:
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AND Tuesday, Wednesday, Friday & Saturday 6:00 pm to 8:00 pm
Max Super Specialty Hospital, Saket, New Delhi: Tuesday & Fridays 10:00 am to 1:00 pm
Max Hospital, Gurgaon: Monday and Thursday 6:00 pm to 8:00 pm

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