Intent to Donate Organs / Tissues
Under the Human Tissue Gift Act
Thank you for your call to say that you want to be an organ and
tissue donor. Your donation can save up to ten lives and improve
countless others! Please make sure that your family knows your
wishes.
Please fill in the information below and mail this form in the
envelope provided. We will send you a temporary donor sticker to
be placed on the front of your Medicare card. Later, when your card
expires, your new Medicare card will have the letter “D” printed on it.
Every year, New Brunswickers die because there aren’t enough
donors. Help save up to ten lives and improve many others by
signing this intent form today.
c Yes, I want to be an organ / tissue donor
Name (please print):
Medicare card number:
Complete address:
Date of birth (d/m/y):
Date:
Donor signature:
Guardian signature:
(if donor is less than 19 years old)
2012.09 | 8946