Patient Consent for Donor Correspondence

Enter the 7 or 8-digit Allograft Serial Number that appears on your Implant Summary Card:*

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you consent to sharing your experience as a tissue recipient with the donor's family? Your response indicates your voluntary consent to such communication.*

Yes
No

Do you consent to being contacted by Artivion regarding opportunities to share your tissue donation experience?*

Yes
No

Do you authorize us to share your thank you letter internally within Artivion and with the Tissue Recovery Partners involved in the tissue recovery process? If yes, you acknowledge that your letter may be shared with Artivion employees and with organizations and their staff members who participated in the donation process. Your letter will be used for internal purposes only and will not be shared publicly or used for marketing purposes without your separate express written consent.*

Yes
No

Is the recipient under the age of 18? If yes, this form must be completed by the recipient's parent or legal guardian with appropriate documentation of guardianship.*

Yes
No

Parent/Guardian Name:

Parent/Guardian Phone:

Parent/Guardian E-mail:

Do you consent to potentially receive correspondence from a donor family and authorize Artivion to facilitate such communication? Your response indicates your voluntary and informed consent to this process.*

Yes
No

Do you consent to having your tissue recipient story shared on the CaringToShare website? Your story may help inspire others and raise awareness about tissue donation. This consent is optional and does not affect your participation in the CaringToShare correspondence program.*

Yes
No