Fillable Nevada Organ Donor Registration Form - Spanish (Department of Motor Vehicles )

Fill Online, Printable, Fillable, Blank Nevada Organ Donor Registration Form - Spanish (Department of Motor Vehicles ) Form

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Nevada Organ Donor Registration Form - Spanish (Department of Motor Vehicles )

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N:\_ResourceDrive\Forms\Hospital and Community Services\NDN-CS-7004.b Donor Registration Form - SPANISH (For sending to the Printing
Company).doc
Rev. 7 Eff: 6/26/15
Para registrarse en línea como donante, visite nuestro sitio Web: www.nvdonor.org
Para más información: DEVUELVA EL FORMULARIO A:
Nevada Organ and Tissue Donor Task Force, Inc.
(775) 784-6171
Donor Network West
(888) 570-9400
Intermountain Donor Services
(801) 521-1755
Sierra Donor Services
(877) 401-2546
Firma del donante:
Fecha:
FORMULARIO DE REGISTRO COMO DONANTE
Nevada: De conformidad con NRS 451.500 y sig.
Para registrarse como donante de órganos y tejidos, favor de llenar el siguiente formulario. Al registrarse
como donante, da su consentimiento para donar sus órganos y tejidos al momento de su fallecimiento. Los
órganos y tejidos se recuperarán con fines de transplante. Sin embargo, en caso de que un órgano o tejido
donado no pueda usarse para un transplante, se harán esfuerzos para usarlos en alguna investigación.
Primer nombre: Apellido: Segundo nombre:
Dirección:
Ciudad:
Estado:
Código postal:
Sexo: Masculino Femenino
Fecha de nacimiento (MM/DD/AAAA):
Correo electrónico (para confirmar su registro como donante):
Últimos cuatro dígitos de su número del Seguro Social (exclusivamente para efectos de verificación de ID):
Limitaciones – Si hay órganos y tejidos específicos que NO desea donar, anótelos aquí. Indique también si no desea
que su donación se utilice para investigación:
¿Cómo se enteró del Registro de Donantes de Nevada?
Nevada Donor Network, Inc.
2061 East Sahara Ave.
Las Vegas, NV 89104
855-NVDONOR (855-683-6667) Teléfono
(702) 796-4225 Fax
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Nevada Organ Donor Registration Form - Spanish (Department of Motor Vehicles )

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Completed 24 December 2020

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