Cornea Eye Donation - Al-Shifa Eye Bank | Al-Shifa Trust Eye Hospital

Donor Information

Full Name

Father/Husband Name

Gender

DOB

Mobile

CNIC

Email

Address

City

Close Relative-1 Information

Name

CNIC

Mobile/Cell

Address

Close Relative-2 Information

Name

CNIC

Mobile/Cell

Address

Brief Medical History

Hepatitis-B

Hepatitis-C

HIV AIDS

Congenital rubella

Active viral encephalitis

Active bacterial or viral meningitis

Active bacterial or fungal endocarditis

Suspected rabies

Intrinsic eye disease

Syphilis

5 + 4 =

Declaration:
I hereby, declare that incase of my death i have donated my eyes for donation to Al-Shifa Trust Eye Hospital and hereby authorize them to remove my corneas for the restoration of vision / Research. It is my will to kindly report my death to Al-Shifa Trust Eye Hospital so that my corneas can be taken on time for the benefit of deserving patients.