Your registry entry will be associated with: Baton Rouge Regional Eyebank
I authorize my organs and tissues to be used for transplant, medical therapy, research and medical education.
By submitting this registration I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a document of gift as outlined in the Louisiana Uniform Anatomical Gift Act. A document of gift, not revoked by the donor before death, is irreversible and does not require the consent of any other person. It also authorizes any examination necessary to ensure the medical acceptability of the anatomical gift.
In order to complete the electronic signature, please type your first and last name and the last four digits of your Social Security Number. All information submitted will be used only for official Registry business and will be kept completely confidential. We will not share, sell or otherwise compromise this information.