Donor Registration Form

Type
Packet Delivery

Jotform
Record Type ID
Status
Donor Address Country
NOK Address Country
GP Address (Country/Territory)
Date Registration Info Received

MonthDayYear
Date
Donor Registration Form
Donor Information
Donor Name*

PrefixFirst NameLast Name
Donor Address
Street Address
Postal / Zip Code
City
Home Phone Number
Mobile
Email*
example@example.com
BSN
Date of birth*

MonthDayYear
Date
Place of Birth*
Marital Status
Name of Spouse / Partner
Is the Donor terminal?
I am in palliative care or have less than six months to live. Please expedite my registration.
Do you have a pacemaker?
Legal Next of Kin Full Name
Legal NOK Relation to Donor

General Practicioner Information
GP Name
GP Phone
GP Address
Street Address
Postal / Zip Code
City
GP Email Address
example@example.com

Privacy - Data Protection & Consent

By completing this form, you agree to your details being securely stored by Fenix Biomed and shared only with the necessary parties involved in the donation process. All information will be handled in accordance with the General Data Protection Regulation (GDPR).

Additionally, you consent to Fenix Biomed obtaining relevant medical information from your GP to determine suitability for donation and assist us in directing your gift to the most appropriate project.
Public Display*
I consent to allow for the Public Display of my body or body part. I understand that they will be used for education, training or research and I will not be identifiable in these images.
Photography & Videography*
I consent to images being taken of my body or body part. I understand that they will be used for education, training or research and I will not be identifiable in these images.
Cremation Remains Requested?*
Partial Cremated Remains that are not matched with a current project will be respectfully returned to the family within approximately 4-6 weeks of the donation.
Next of Kin Notification of Test Results*
If my blood test returns a positive result, (you are infected) I would appreciate FenixBiomed to disclose these test results to my Next of Kin as signed on the Witness Statement.
Next of Kin Notification - Family Letter Request*
I would like my loved ones to receive a letter outlining the research programs going on at the time of my donation.
Organ Donor Registry*
I am a registered organ donor in the donor registry.

Authorization & Consent
Authorization for Whole Body Donation

I authorize the donation of my body for the purpose of medical education, research, and training. This decision is made purely out of altruistic intent, without any expectation of financial compensation for myself or my family.

I also give permission for the procurement of tissues, organs, and anatomical specimens, including but not limited to my whole body, head, limbs, spine, and internal organs for anatomical examination, education, training and research purposes.

Acknowledgement of Understanding

I confirm that I have read Fenix Biomed's Donation of Body for Anatomical Examination booklet and understand the information provided. I acknowledge that while every effort is made to accept donations, acceptance is not guaranteed.

Medical Information & Testing

I authorize the release of my full medical history and any relevant medical records to Fenix Biomed before or after my passing. Additionallu, I consent to blood teting, which may include, but is not limited to, HIV, hepatitis B, and hepatitis C.

Cremation & Final Arrangements

I understand that any cremated remains returned to my family will not include any tissues, organs, or anatomical specimens used for medical education or research. Additionally, due to the nature of whole body donation, an open-casket viewing is not possible, and no uncremated remains will be returned.

By signing this document, I agree to hold Fenix Biomed and all affiliated organizations harmless from any liability related to my donation. This contribution is made in the spirit of advancint medical education, research, and training.
Donor Signature

I wish to donate my body after my deatch, with the understanding that it may be used for anatomical examination, education, training, and research to further the stidy of the human body and its functions.
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Photo Identification

Passport, Driver's License, ID Card

If using a passport, please provide a photo of both the front and back of the photo page.
Donor ID Photo (Front) Passport, Driver's License or ID Card*
Donor ID Photo (Back)*
Witness Signature

I confirm that I witnessed the potential donor sign this document voluntarily and of their own free will.
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Photo Identification

Passport, Driver's License, ID Card

If using a passport, please provide a photo of both the front and back of the photo page.
Witness ID Photo (Front). Passport, Driver's License or ID Card
Witness ID Photo (Back)

Next of Kin Contact Info
Next of Kin Address
Street Address
Postal / Zip Code
City
Next of Kin Email
example@example.com
Next of Kin Phone (Home)
Next of Kin Phone (Mobile)
Should be Empty:

Donor Registration Form

Donor Information

General Practicioner Information

Authorization & Consent

Next of Kin Contact Info