Mtera Organ Donation Pledge Form Under Section 8 El

MEDICAL (THERAPY, EDUCATION AND RESEARCH) ACT 1972
ORGAN DONATION PLEDGE FORM UNDER SECTION 8

(This form may take you 5 minutes to fill in. Please complete all particulars in BLOCK LETTERS.)
For Official Use Only
FULL NAME
(as in identity document (ID))
ID NO.
CITIZENSHIP /
RESIDENTIAL STATUS Singapore Citizen Singapore Permanent Resident Others (please specify):
DATE OF BIRTH D D M M Y Y Y Y SEX Male Female
RACE Chinese Malay Indian Others (please specify):
HOME ADDRESS
POSTAL CODE CONTACT NO.
I hereby donate the following upon my death (please tick ‘  ’ one box):
Whole body donation Any needed organs or parts Any organs or parts specified here:
My donation is for the purposes of (please tick ‘  ’ all applicable boxes):
Transplant and / or therapy Medical / dental education, research, and / or advancement of medical / dental science
[OPTIONAL SECTION] A gift of all or any part of the body of a deceased person may be made to a specified donee* or without specifying a donee. This
section may be left blank if you do not wish to specify a donee for the purpose(s) indicated above upon death.
I wish to specify the following as donee, for the purpose(s) indicated above upon my death (optional):
Donation to specified individual for therapy or transplantation needed by him / her (if applicable):
FULL NAME (as in ID)
ID NO.
Donation to specified approved hospital, or approved medical / dental school, college, or university (if applicable):
NAME OF HOSPITAL OR MEDICAL / DENTAL SCHOOL, COLLEGE OR UNIVERSITY
If the specified donee does not or is unable to accept, and / or does not need my body / organs upon my death
(please tick ‘  ’ one box):
I agree to donate my body / organs to other donees for the purposes I have indicated above.
I do not agree to donate my body / organs to other donees.
Remarks
*Donee refers to any specified individual, any approved hospital or approved medical / dental school, college or university.
Please note that under the Medical (Therapy, Education and Research) Act 1972:
1. A gift of a body or any part thereof may be revoked by the donor at any time.
2. If you have specified an individual as donee for the purposes of therapy or transplantation needed by him / her, kindly note that your organs will not be preserved for this
purpose, if the specified donee does not require therapy or transplantation upon your death.
3. You are encouraged to discuss your decision to pledge the donation of your body / organs with your family members or next-of-kin so that they will be aware of your wishes.
These members will be instrumental in ensuring that your wishes are carried out.
4. Upon your death, your health records (including electronic health records) will be accessed, to facilitate assessment of the suitability of your body / organs for donation.
SIGNATURE DATE D D M M Y Y Y Y
Please note that a person who is mentally disordered may not pledge the donation of his / her body / organs through submitting this form.
FIRST WITNESS’ PARTICULARS* SECOND WITNESS’ PARTICULARS*

FULL NAME (as in ID) FULL NAME (as in ID)
ID NO. ID NO.
DATE OF BIRTH D D M M Y Y Y Y DATE OF BIRTH D D M M Y Y Y Y
CONTACT NO. CONTACT NO.
HOME ADDRESS HOME ADDRESS
POSTAL CODE POSTAL CODE

RELATIONSHIP RELATIONSHIP
SIGNATURE SIGNATURE
DATE D D M M Y Y Y Y DATE D D M M Y Y Y Y
In the event of my death, please contact:

FULL NAME (as in ID) CONTACT NO.
HOME ADDRESS
POSTAL CODE
*Witness must be 21 years old and above.
MD186
09/2022
Singapore 169608
c/o Singapore General Hospital
Outram Road
NATIONAL ORGAN TRANSPLANT UNIT
PERMIT NO. 01589

BUSINESS REPLY SERVICE
Singapore only.
posting in
addressee. For
be paid by
Postage will National Organ Transplant Unit
Note:
1. This organ donation pledge form only applies to individuals aged 18 years and above.
2. Please note that the organ(s) indicated in this organ donation pledge shall be recorded in the organ
donation pledge registry and updated with any other organ pledge(s) made previously.
3. This form is invalid if it is not duly completed.
4. Please forward the completed form to the following address:

National Organ Transplant Unit
c/o Singapore General Hospital
Outram Road
Singapore 169608
5. If you do not receive an acknowledgment to your pledge for organ donation within 3 weeks,
please contact the Officer-in-Charge at the above address or contact 63214390.

Mtera Organ Donation Pledge Form Under Section 8 El

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Mtera Organ Donation Pledge Form Under Section 8 El

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MEDICAL (THERAPY, EDUCATION AND RESEARCH) ACT 1972

ORGAN DONATION PLEDGE FORM UNDER SECTION 8

For Official Use Only

FIRST WITNESS’ PARTICULARS* SECOND WITNESS’ PARTICULARS*

CONTACT NO. CONTACT NO.

HOME ADDRESS HOME ADDRESS

POSTAL CODE POSTAL CODE

In the event of my death, please contact:

PERMIT NO. 01589

3. This form is invalid if it is not duly completed.

4. Please forward the completed form to the following address:

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