Donor Registration Form
Nevada: Pursuant to NRS 451.500et seq.
The individual named below consents to be listed in the Donor Registry for the
State of Nevada. This is an authorization for organ & tissue donation to be made upon
their death.
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Full Name:
Current Address:
Donor Comments: Use all my organs: Yes _____ No_____ Use only the following organs/tissues___________ Use all my tissues Yes _____ No_____ ______________________
Gender (required):
Race (optional):
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Donor Signature: Date
Under the
Nevada Revised Statute, an anatomical gift made by a donor and not
revoked by the donor before death is irrevocable and does not require consent or
concurrence of
any person after the donor’s death. The law also authorizes any examination
necessary to assure
the medical acceptability of the anatomical gift.
In order to
comply with the wishes of this individual, organ, tissue, and eye recovery
agency
representatives are authorized to examine or remove copies of medical records,
obtain blood and
tissue samples to test for hepatitis, HIV, syphilis, and conduct any other
examination to determine the
medical suitability of the anatomical gift.
A different
location may be needed to carry out the recovery of donated tissues. In that
case,
the body may be transferred to an alternative surgical facility for the recovery
of tissues.
Information Contacts: Return Form to:
Nevada Organ and Tissue Donor Task Force Nevada Donor Network
775-784-6171 2085 Sahara Ave.
Las Vegas, NV 89104
California Transplant Donor Network 702-796-9600 Phone
888-570-9400 702-796-4225 Fax
Intermountain Donor Services or
801-521-1755
The Transplant Network
Second Chance Foundation 1664 N. Virginia St.
702-369-5876 Reno,
NV 89557-0454
University of Nevada/School of Medicine/MS/0454
(775) 784-6171 Phone (775) 784-4828 Fax