Donor Body Registration – Step 3 - United Tissue Network

High Risk History About the Donor – Reason for Decline

Thank you again for your interest in whole-body donation with cremation.

You’ve completed steps 1-2 of 9 for the donation. Please use the same name and email information that you used for the first part of the donation process.

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Donor First Name

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Donor Last Name

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Your Name

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Your email address

Please complete Step 3 of 8 now.

This series of questions, steps 3 through 8, will help determine if your loved one or patient would be a good candidate for whole-body tissue donation. These questions will cover topics such as medical history, past surgeries, past diseases, drug use, and high-risk sexual behavior.

please provide details.

Please provide details.

General History of the Donor

These questions pertain to the general history of the donor. Please select any that apply.

When, where, and for how long?

Please list the medication(s) and how long the medication has been taken.

If yes, how long?

Please list the medication(s) and how long the medication has been taken.

If yes, please list medication and how long the medication has been taken.

Please describe the amount smoked per day. How many years? When the last time the tobacco was used?

Please describe the amount consumed per day. How many years? When the last time alcohol was consumed?

Please provide detail.

Please explain.