Anatomical Bequest Form
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- Lydia Lucas
- 7 years ago
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1 Anatomical Bequest Form Anatomy, School of Medicine National University of Ireland, Galway I wish to donate my body after death to Anatomy, School of Medicine, NUI Galway. I understand that my body may be used for any or all of the following purposes: Anatomical Examination this term describes the teaching of the structures and functions of the human body to students or healthcare professionals; Research this term describes scientific studies which improve the understanding of the human body and scientific studies that develop and test novel medical technologies or devices that will enhance the quality of life of others, Education and Training these terms describe the training of healthcare professionals, usually those learning surgical techniques, as opposed to anatomical examination. Anatomical donation is an important aspect of healthcare training. Donated bodies are retained for a period of up to three years before release to next-of-kin. In certain circumstances body donations may not be accepted.
2 DONOR First Name Middle Name Family Name Donor s Home Date of Birth Marital Status Occupation is/was Religion Please indicate where you choose to be buried: University Plot, Bohermore, Galway: Your own funeral Directors: your own coffin Family Plot (please state place): Cremation: Donor s Signature: Date signed: WITNESSES The Donor has signed this Authorisation Form for Anatomical Donation, and we, in his/her presence and at his/her request, have provided our names as witnesses to his/her signature. We state that the Donor is at least eighteen years of age and appears to be of sound mind and is not under, or subject to, undue influence. We further state that we are at least eighteen years of age. Witness 1 Signature Date signed Witness 2 Signature Date signed
3 Additional contacts NEXT OF KIN INFORMATION Solicitor General practitioner
4 Current Anatomy legislation permits retention of a donated body Anatomy for a period of up to three years, after which time the donor s remains will be released according to their stated wishes. Extended retention of your organs or tissue indefinitely for teaching or research purposes is allowed only if you have specifically consented to this. With this in mind, please consider the following questions 1. (Please tick appropriate box) I consent to the extended retention of parts of my body OR I do not wish retention of parts of my body beyond the 3 year stipulation of the Anatomy Act 2. (Please tick appropriate box) I consent to the use of images derived from my unidentifiable body or body parts OR I do not consent to the use of images of my body or body parts Please note that choosing not to consent to these requests will not affect your wish to donate your body for a period of up to three years.
5 DONOR MEDICAL HISTORY FORM Listed below are common medical conditions. If you either suffer from or have suffered in the past from any of these conditions, put an x in the box by the condition listed. CONDITION Breast Cancer Cervical Cancer Prostate Cancer Colon Cancer Skin Cancer Other Cancer Heart Attack Heart Bypass surgery Heart Balloon Surgery Asthma Stroke High Cholesterol Diabetes High Blood Pressure Emphysema Pacemaker HIV Tuberculosis Hepatitis CONDITION Lung Problems Arthritis Back Problems Hearing Problems Dental Problems Skin Problems Kidney Problems Osteoporosis Chicken Pox Mononucleosis Measles Mumps Migraine Headaches Seizures Joint replacement Medical device implant MRSA Creutzfeldt-Jacob disease Other (please specify) Please list any Surgeries you have had in the space below: Thank you for completing this form. The information you have given us will be treated with the strictest confidence. This information is to help give students a greater understanding of the human body and how it deals with common medical conditions. Please detach and return completed forms to: Anatomical Donor Program Anatomy, School of Medicine NUI Galway University Road Galway
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Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of