national organ donor registration form

PLEDGE YOUR ORGANS & TISSUES BY FILLING THIS FORM.
1. YOUR PERSONAL DATA
Name :
Old IC No. :
New IC No. : - -
Dateof Birth : / / (DD/MM/YY)
Race : Malay Chinese Indian Others
Sex : Male   Female
Address :
Tel No. :
Email :
 
2. MY NEXT OF KIN
Name :
Relationship :
 
3. WHAT TO DO NEXT?
Please let your family know of your decision to be an organ and tissue donor upon death.
 
4. YOUR WISH
I wish that after my death:-
a) All my organs and tissues
b) OR
  • Kidneys
  • Heart
  • Liver
  • Lungs
  • Eyes
  • Bones
  • Skin
be removed for the purposes of transplantation.
 
     
________________________________
  
_______________
Signature  
Date
 
PRINT OUT and MAIL this form to the below address
as your SIGNATURE is required.
 
 

SEND TO
Pusat Sumber Transplan Nasional
(National Transplant Resource Center)
Hospital Kuala Lumpur, Jalan Pahang,
50586 Kuala Lumpur, Malaysia.