משרד הבריאות

Please print this form, fill it out, and fax it to ADI at 03-6957344

DONOR'S DECLARATION

To: ADI - Israel Transplant
Noah Mozes St.15 ,67442 Tel-Aviv
Tel:03 - 6957369, Fax:03 - 6957344
1-800-609-610

Last Name___________ First name___________ I.D. No______________ Year of Birth*_________

Address_____________________ Town___________ Zip Code______________ Tel____________

In the hope that I will be able to help another person after my death, I hereby bequeath my:

kidney heart liver lungs cornea skin

any organ from which another person may benefit

Under the condition that a religious leader,
chosen by my family, approves the donation

This bequest is for purposes of tranplanation only.
* Over 18 Only

Date_________ Signature _________