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Register to Donate Life
First name
*
Middle name (Optional)
Last name
*
Donation preference
*
I wish to donate any needed organs and tissue.
I wish to specify limitations.
I wish to donate only the following:
Organs
Heart
Lungs
Liver
Kidneys
Pancreas
Small Intestine
Eyes
Whole eyes
Corneas
Tissue
Skin
Bone
Veins
Tendons & ligaments
Heart valves & associated cardiovascular tissue
Duke Miracles in Sight (“MiS”) BioSight Research Program
*
I agree to donate my eyes/corneas for the Duke-MiS BioSight research program.
I do not agree to donate my eyes/corneas for the Duke-MiS BioSight research program.
Do you have an eye disease? Click to provide details.
Eye Disease (Check all that apply)
Macular Degeneration (AMD)
Glaucoma
Keratoconus
Myopia
Fuch’s Dystrophy (and other cornea disease)
Retinitis Pigmentosa
No known eye disease
Other
Other
Your eye clinic or name of provider
Should it be determined that the consented gifts are unsuitable for transplantation...
*
authorization is granted for these gifts to be placed for medical research/education purposes.
I do not give consent for these gifts to be placed for medical research/education purposes. The gift should be appropriately discarded.