Eye Donation Pledge Form

I pledge to donate my eyes for the purpose of transplantation, medical research or education.

Title *

Select Mr. Ms. Mrs Other  

Name of Donor *

Village/Town/City *

PIN Code *

State *

Date Of Birth *

Age *

Mobile No *

Email *

I further direct my next of kin, here in named, to execute this gift after my death. Direction to the next of kin as per wishes of the donor.

Title *

Select Mr. Ms. Mrs

Next-of-Kin Name *

Address *

City *

State *

PIN Code *

Mobile No *

Email

I Permit Drishti Eye Institute, Dehradun to contact me

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