Browse:HomeDonor Registration Form Personal Details Select one* -OtherAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Gender Select one* FemaleMale Date of birth* How did you hear about us? Select one Event Facebook Instagram MVD Other Radio Television Twitter Abrazo Arizona Heart Hospital Abrazo Arrowhead Campus Abrazo Central Campus Abrazo Scottsdale Campus Abrazo West Campus Adelante Healthcare Advertising Agua Fria High School American Heart Association American Liver Foundation Arizona Humane Society Arizona Spine and Joint Hospital Arizona Vegetarian Festival ASU Avondale District Wellness Ayryonna Davis AZ Optical Systems AZBlue B For Life Banner Baywood Medical Center Banner Boswell Medical Center Banner Del E. 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Lincoln Medical Center HonorHealth Scottsdale Osborn Medical Center HonorHealth Scottsdale Shea Hospital HonorHealth Scottsdale Thompson Peak Hospital Hospital In Honor of a Donor Intel Health Fair Internet Isaac School District Joshua Jones Memorial Shoot Julianne Orren Kidney Walk Knights of Columbus Latino Pride Lawyer Lee Williams High School LifeDonorUSA Little Colorado Medical Center Liver Life Walk LSA/SQL Laboratory Sciences of AZ March for Babies Maricopa Integrated Health System Maricopa Salsa Festival Matthew Owen Maxine Rose Mayo Clinic Hospital McDowell Mountain Music Festival Mercy Gilbert Medical Center Mesa Community College Mesa Starlight #16 Mexican Consulate Midwestern Mortuary Moth the Flame concert Mountain Ridge High School Mountain View High School Movie Theater National Kidney Foundation of Arizona Nationwide Insurance NAU Campus Challenge Newspaper Nico Santos Northern Arizona VA Health Care System Northwest Medical Center One Medical Oro Valley Hospital Pat's Run PayPal Health Fair Perry High School - Sports Medicine 39115 PetSmart Phoenix Baptist Hospital Phoenix Children's Hospital Phoenix New Times Phoenix New Times Phoenix Pride Phoenix Rising Health Fair and Soccer Clinic Phoenix Union HS District Pinnacle Transplant Technologies Robert Brink Roots n Boots San Luis High School Santa Cruz Valley Regional Hospital Science Care Sejal Patel Service Arizona Seton Catholic Preparatory Sierra Linda High School Somos Peoria St. Joseph's Hospital and Medical Center St. Luke's Medical Center Summit Healthcare Regional Medical Center Tempe Fire Medical Rescue Department Tempe St. Luke's Medical Center Tempe Tarada Tonopah Valley High School Chapter 39352 Transplant Community Alliance Transplant Families Tucson Festival of Books Tucson Liver Walk Tucson Medical Center Tucson Parade of Lights Tucson Weekly Tucson Weekly U of A Campus Challenge United Surgical Partners United Tissue Network Univision USPHS - Whiteriver Indian Hospital Valente Caywood Valley Hospital Volunteer Walgreens West Pharma Health & Wellness Fair West-MEC NE Pharmacy Tech West-MEC Northwest West-MEC Physical Therapy Wickenburg Community Hospital Wilson Community Fair Winslow High School Workplace Yavapai Regional Medical Center Youngker High School YOLO Youth Grant Youth Summit YouTube Yuma County Employee Health Fair Yuma Health Fair Yuma Regional Medical Center Intended Purpose* Transplant and research Transplant I agree that detailed information regarding my donation, from recovery through transplantation, has been made available to me through this registration. By submitting this registration I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a registration of my document of gift as outlined in the Arizona Uniform Anatomical Gift Act. A document of gift not revoked by the donor before death is irreversible and does not require the authorization of any other person. More information about your donor registration The following information is intended to provide you with information on the process of donation. If you have any questions or would like further explanation on this section, please call Donor Network of Arizona at 800-94-DONOR (800-943-6667). I understand and authorize the following as indicated by my signature for authorization at the end of this document: Donation requires both a physician’s legal declaration of death and the decision to help others. There is no cost to the family or estate for anything related to the donation. All unrelated hospital charges as well as funeral expenses remain the responsibility of the family or estate. The privacy and the confidentiality of the donor and the decision for donation will be respected. Information will be shared with those individuals and organizations involved in the donation process; this will include hospital and transplantation staff, the funeral provider and the medical examiner’s office. Copies of medical records, the death certificate and the autopsy report, if there is one, will be obtained and reviewed. Part of the donor evaluation process requires transmissible disease testing. These tests are performed to ensure the safety of transplant recipients. Arizona laws requires that positive confirmed tests be reported to the Arizona Department of Health Services. Other evaluative tests, procedures and biopsies may also be performed. For organ donation, the recovery of the spleen and lymph nodes takes place to ensure the compatibility between the donor and transplant recipients. Blood vessels may also be recovered for the purpose of safe organ transplantation. The placement of organs and tissues is directed by local, state and federal guidelines and transplantation standards. At times, tissue may be sent to help people in other countries. Through medical breakthroughs, recovered tissue can be reshaped and reformed to accommodate a variety of transplant needs. Also, in order to benefit the greatest number of recipients, both nonprofit and for-profit organizations may be involved in the process. The work of recovery in the donation process is performed with care and does not normally interfere with funeral arrangements. Donation includes the careful restoration of the donor. Bruising and swelling are rare but can occur. For tissue donation, the donor may be transported to a donation facility for recovery procedures. The medical examiner’s office will determine if an evaluation or autopsy is necessary and if any restrictions regarding the donation process are required. Following the recovery of anatomical gifts and the medical examiner’s evaluation (if applicable), funeral plans and/or other arrangements may proceed. Congratulations! You have successfully registered! Congratulations, you are officially a registered donor in the state of Arizona. Thank you for joining the over three million Arizonans who have also made the commitment to saving and improving the lives of others. Please print and retain the Donor Confirmation Letter for your records, as you will not receive anything by mail. Send an email or postcard to your family and friends to let them know you are a registered donor. Add your name or add a loved one’s name to the Wall of life. Logout of your donor profile. About Your Donation I wish to donate any needed organs/eye/tissues I wish to specify my donation Check "no" to any items that you DO NOT wish to donate. Click an item name for more detailed information about that item or items. Organs Heart Yes No Kidneys Yes No Small Intestine Yes No Lungs Yes No Liver Yes No Pancreas Yes No Tissues Eyes Yes No Heart (For Valves) Yes No Bone & Associated Tissue Yes No Skin Tissue Yes No Veins & Arteries Yes No Pericardium Yes No ×Close Authentication In order to edit your information in the future, please enter a password that is at least 8 characters long with at least two of the following - capitals, numbers, symbols. Submit