Don't forget to call for your Family Discussion Certificate after completing this form to become an organ and/or tissue donor.
Please Print, Detach and Give to Your Next of Kin After Your Family Discussion!
This is to inform you of my wishes to be an organ and tissue donor if the occassion arises. Please honor my wishes by informing medical personnel that I am a donor. I want to help save lives.
your signature date
I hereby acknowledge that I have had a family discussion regarding organ and tissue donation with the designated person above.
next of kin signature date
After your family discussion, both parties can receive a Family Discussion Certificate by calling (800) 393-2839 or (202) 865-4888.

Signed by the donor and the following two witnesses in the presence of each other,
signature of donor donor date of birth
date signed city & state
witness witness
This is a legal document under the Uniform Anatomical Gift Act or similar laws. For further information consult your physician or:
Ambulatory Care Center
2041 Georgia Ave., NW
Suite 3100
Washington, DC 20060
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