Eye Donation Pledge Form

I give my eyes for the purpose of transplantation, medical research or education. Pledge by the donor *
 
Name of Donor *
Village/Town/City *
PIN Code *
State *
Date Of Birth *
Age *
Mobile No *
Email *
I further direct my next of kin, herein named, to execute this gift after my death. Direction to the next of kin as per wishes of the donor *
Next-of-Kin Name *
Address *
City *
State *
PIN Code *
Mobile No *
Email
I am Happy Drishti Eye Institute, Dehradun to contact me
Captcha *