Computerised pre-registration for potential organ donor card
Please print and return by fax or mail
Name:
Firstname:
Mrs
Miss
Mr
Address:

Zip code:

City:

Country:

Phone:

Fax:

E-mail:

Date of birth:
Date:.......................................
 Signature: ...................................

For a minor person, signature of the legal representative:


I am interested in the establishment of a computerised registry containing my consent to organ retrieval from my body in the event on my death.

I am interested in the establishment of a computerised registry containing my consent to organ retrieval from my body in the event of my death, with the exception of the following organs:





I am interested in the establishment of a computerised registry containing my decision not to consent to organ retrieval from my body in the event of my death.
This document must be sent to
Fondation "Passez le Relais"
by fax +41 21 964 19 26
or
by mail
Fondation "Passez le Relais"
P.O. Box 90
CH - 1816 Chailly-Montreux

As soon as the computerised registr with all of its safeguards is ready for implementation, "Pass the Baton" will contact you in order to inform you of its official introduction.
No medical data is required. Your decision may be changed in writing to the same address at any time. Only your choice is registered.