Non-hospital death referral

Non-Hospital Death Referral

Use this form to submit information directly to Gift of Life Michigan on a potential deceased tissue donor.
Do any of the following medical rule outs apply?
You only need to select one if more than one are applicable
Medical Rule Out

The deceased does not meet the criteria for tissue donation. You do not need to submit any additional information. Thank you for your commitment to honoring the gift of tissue donation. If you believe there is a mitigating factor or need to contact us please call 800-482-4881.
Please fill out the Required Information fields and any fields you can answer under Additional Information.

Gift of Life Michigan may call you regarding any questions or concerns on your referral. You can also call us with any updates at 800-482-4881.

Required Information
Your information

Information for us to make follow up communication
Referring Person*

First NameLast Name
Phone Number *
The best number to contact you back, or call the dispatcher.
Your Organization*
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Time of Death: * Date* Time*
Where did the death occur?
Disposition
Is Next of Kin known?
Relationship to deceased:
Ex: spouse, child, guardian
Next of Kin or Other Contact:

First NameLast Name
Phone Number:
NOK phone number
Is NOK aware of the death?
Brief circumstances:
Please indicate any extensive trauma (ie: open fractures, wounds)

Non-Hospital Death Referral