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.
- 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.Format: (000) 000-0000.
- 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 numberFormat: (000) 000-0000.
- Is NOK aware of the death?
- Brief circumstances:
  Please indicate any extensive trauma (ie: open fractures, wounds)

Medical Examiner
Has the medical examiner requested an autopsy?
Case Number
Name of investigator contacted
Contact number for investigator
Investigator's phone numberFormat: (000) 000-0000.
Funeral Home Information
Has family selected a funeral home?
Name of Funeral Home
Add city or location of funeral home if known
Has the funeral home been contacted yet?
Has the funeral home picked up the body?

Additional Relevant Information
Is there any other information that you think we should know?
Upload any relevant document(s) you want to share:

Cancelof
Would you like a copy of this referral emailed to you?
Email Address:
example@example.com
Should be Empty:

Non-Hospital Death Referral

Medical Rule Out

Your information

Additional Patient Information

Circumstances of Death

Medical History

Additional Contact Information

Medical Examiner

Funeral Home Information

Additional Relevant Information