State your intent to not donate organs and tissues: Refuse Organ Donation Form
What is a Refuse Organ Donation Form?
It can be important to openly discuss post-mortem plans with your family and loved ones. A Refuse Organ Donation Form can help document those plans in an official capacity. Deciding whether or not to donate your organs and tissue is an important decision - and you're well within your rights to refuse. If you've already decided you don't want to donate, talk to your family and give them a formal copy of your wishes. Having everything in writing makes the matter simple for your family and helps ensure your wishes are clear and understood. Having a Refuse Organ Donation Form is a great start to making your decision official.
When to use a Refuse Organ Donation Form:
- You don't want your organs or tissue donated when you pass.
- You want to revoke a past desire to donate organs or tissues.
- You want to provide written proof of your wishes.
Sample Refuse Organ Donation Form
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REFUSAL TO
DONATE ORGANS
I, , of , , , refuse to donate any of my organs, tissues, or parts to be used for any purpose upon my death.
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
I witnessed that this document was signed in my presence by the Nondonor. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
I witnessed that this document was signed in my presence by the Nondonor and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
I witnessed that this document was signed in my presence by at the direction of and in the presence of the Nondonor who was physically unable to sign. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
I witnessed that this document was signed in my presence by at the direction of and in the presence of the Nondonor who was physically unable to sign and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
Parent(s) Guardian(s)
| Signature: | __________________________________________ |
I witnessed that this document was signed in my presence by the Nondonor and the Nondonor's . I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
I witnessed that this document was signed in my presence by the Nondonor and the Nondonor's and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
Parent(s) Guardian(s)
| Signature: | __________________________________________ |
| Signature: | __________________________________________ |
| Witness Signature: | __________________________________________ |
| Witness Signature: | __________________________________________ |
