C.M.R. 10, 144, ch. 52, app 144-52-A
PERMISSION FOR ORGAN DONATION BY NEXT OF KIN*
Hospital Name: ________________________________________________________
I /we__________________ of________________ __________________ _(_______)_
next of kin/guardian street address town and state relationship to patient
hereby give my/our permission to_________________ and the medical staff thereof, to
hospital name
authorize the removal and subsequent donation of the following organ (s) or tissue(s)
__ any appropriate organ
__kidney __eye/cornea __heart __heart/lung __liver __pancreas __bone
of__________________to be used for such purposes, Including organ transplant,
name of patient/deceased
as______________________may deem best, including transfer of such organs to regional hospital name medical Institutions located outside the State of Maine.
Permission is further granted for the -transfer of the patient to the hospital where the removal of the above mentioned organ(s) will occur and for the performance of any procedures -the are determined necessary in association with the removal of these organs.
It Is understood that if permission is given prior to the actual death of__________________, patient name It will become effective only upon such death; and such permission may be relied upon by the _______________________, members of its medical staff and any medical regional hospital name institutions which may ultimately receive the organs unless said permission is revoked in writing prior to pronouncement of death and removal of the donated organs.
______________________________ __________________________
signature of next of kin/guardian witness
_____________________________ __________________________
street witness
_____________________________ Witnessed to obtaining signature
city state ZIP this______ day of_______, 19
Permission obtained by
____________________________________________________________________
Name title
*The following is a list, in order of priority, of persons so authorized: patient's spouse, patient's adult son or daughter, patient's mother or father, patient's adult sister or brother, patient's guardian at the time of death, other person authorized to dispose of patient's body. (See 22 MRSA §2902(21).)
C.M.R. 10, 144, ch. 52, app 144-52-A