Browse:HomeDonor Registration Form Personal Details Select one* -OtherAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Sex Select one* FemaleMaleNon-binary Date of birth* How did you hear about us? Tempe Tardeada 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 millions of 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. Join our social media community to share inspiring stories of hope and learn more about organ and tissue donation. 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. To remove your registration as an organ and tissue donor in the DonateLifeAZ Registry, click here. All other profile changes and specifications can be made by clicking "edit" below. 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
