M.D. Global,LLC

15600 E. 19th Ave. Unit H. Aurora, CO 80011
(303) 931-2348

Self Authorization for Whole Body Donation

By my signature below, I hereby swear that I am eighteen (18) years of age and of sound mind. I hereby authorize and direct the donation upon my death of my whole entire body (my "Donation") to M.D. Global, Llc ("M.D."), based upon the to the following disclosures, terms, and conditions:

 

  1. The body of the deceased is hereby irrevocably donated to M.D. for medical education and/or research ("Donation").
  2. There will be no compensation or charges for any expenses associated with any use of the Donation.
  3. The under signed has had adequate time to consult with the decedent's family, friends, doctors, and legal advisors.
  4. M.D. is not obligated to notify anyone, including the decedent's family, about the Donation.
  5. Due to the time sensitivity of the Donation, any funeral/memorial service will not include an open viewing.
  6. The Donation may require embalming procedures (and/or M.D.'s proprietary tissue preservation procedures) and surgical disarticulation of the limbs, head, spine and removal of other tissues.
  7. Although the Donation may be examined and used by multiple medical professionals, doctors, research personnel,and other
  8. M.D.staff(collectively"M.D.'s Affiliates"), the Donation will not be displayed for the general public.
  9. The Donation may be used in whole or in part within the domestic United States of America, or internationally, for unlimited multiple educational, scientific, clinical, and/or medical research purposes, which may include genetic research.
  10. M.D. will treat the Donation with respect and dignity and cremation will occur following the use of the Donation.
  11. I fully understand that the soft tissue of the Donation cannot and will not be returned to anyone in cremated form or otherwise.
  12. There are no guarantees that the Donation will be useful or that it will contribute to the success of any research.
  13. M.D.is a for-profit company which enters into business transactions and accepts consideration for services rendered in making whole body donations available to for-profit and not-for-profit entities engaged in medicale ducation and research.
  14. M.D. operates in accordance with applicable standards of the Uniform Anatomical Gift Act (UAGA), published ethical guidelines, as well as state and federal statutes and regulations.
  15. M.D. is not required to provide anyone (including, the decedent's family members, descendants, or legal representatives)with any information or inspection of the Donation or to any research, clinical uses, findings or outcomes associated there with.
  16. Health protected information,as defined by the Health Insurance Portability and Accountability Act("HIPPA"), will be collected by M.D.and coded to maintain anonymity and confidentiality.
  17. Testing results may be reported to M.D.’s Affiliates and government agencies to comply with federal and state laws.
  18. TESTING: To evaluate the potential use of the Donation, specimens or other bodily fluids will be derived from the Donation and then tested to determine the presence of certain communicable diseases including, but not limited to, human immunodeficiency virus(HIV) and Hepatitis B and C('Testing"). Positive results may limit or preclude the use of the Donation.
  19. I hereby authorize the Testing, disarticulation, dissection, research, tissue disposition, cremation and/or interment of the Donation
  20. MEDICAL RECORDS RELEASE: The undersigned authorizes the release of the decedent’s medical information such as hospital/physician records and autopsy reports to M.D.and M.D.’s Affiliates to determine the suitability of this donation.
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND ALL OF THE PROVISIONS ABOVE: *
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Witness Signature *
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