Victoria Hospital, Near City Market, Fort Road, Bengaluru, Karnataka 560002
Call: +91-80-26701150
@ Victoria Hospital
Bangalore - 02
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Skin Donation Pledge Form
I Mr./Mrs. (required)*
agree to pledge my skin, by donating my skin after my death. I grant permission for the recovery of my skin for purposes of transplantation and research.
I also would like to Donate my
Eyes
Organs
Date of Birth
Mobile Number*
Email*
Address
Name of Next of Kin**
Kin's Relationship
Mobile Number
"You Pledging Skin Today means You are destined to Save Someone's Life One Day."
*Mandatory Fields
**Next of Kin needs to be Close relative, over 18 years of age
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