WILLIAMS SYNDROME TISSUE DONOR PROGRAM REGISTRATION The Salk Institute for Biological Studies Laboratory for Cognitive Neuroscience (858) 453-4100 x1222 (800) 434-1038 FAX: (858) 452-7052
Completion of this registration form provides important information needed to coordinate tissue recovery in the event of death of the donor. After the Laboratory for Cognitive Neuroscience receives this registration form, you will receive a packet containing Anatomical Gift Act forms and Access to Medical Records forms and other materials.
DONOR INFORMATION
I, wish to register myself (or my dependent) as a tissue donor with the Laboratory for Cognitive Neuroscience at the Salk Institute for Biological Studies.
NAME OF DONOR DATE OF BIRTH STREET ADDRESS CITY STATE ZIP CODE PHONE (day) PHONE (evening)
PLEASE PROVIDE A BRIEF MEDICAL/FAMILY HISTORY
DIAGNOSES: DATE DIAGNOSED DATE DIAGNOSED DATE DIAGNOSED DATE DIAGNOSED DATE DIAGNOSED
PARENT, GUARDIAN, or HEALTH CARE PROXY INFORMATION NAME RELATIONSHIP TO DONOR STREET ADDRESS CITY STATE ZIP CODE PHONE (day) PHONE (evening) FAX