Pledge Your Eye – Prabha Eye Clinic

Let us know how to get back to you.

I hereby give complete consent to donate my eyes to help others get a fresh lease of life, or for any medical research as required.

NAME OF THE DONOR *

ADDRESS OF THE DONOR *

CITY *

STATE *

DATE OF BIRTH *

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PINCODE *

MOBILE NUMBER *

EMAIL ADDRESS * Example: user@website.com

I authorise the person mentioned below to help take the initive to complete the formalities after my death.

TITLE *

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NAME *

ADDRESS

CITY

STATE

PINCODE

MOBILE NUMBER *

EMAIL ADDRESS Example: user@website.com