Donor-Consent-Form_2022

THIS FORM IS SUPPLIED FOR THE CONVENIENCE OF DONORS AND IS IN NO WAY
LEGALLY BINDING IF THE DONORS OR THEIR RELATIVES AT ANY TIME WISH TO ALTER
OR REVOKE ANY PART THEREOF.
Please return the original copy of this form in the reply paid envelope enclosed, or:
Human Bequest Coordinator
Discipline of Anatomy
College of Medicine and Dentistry
James Cook University
Townsville QLD 4811
Donor Consent Form

PLEASE PRINT ALL INFORMATION CLEARLY
Surname: (Mr/Mrs/Miss/Ms/Dr) ____________________________________________
Given Names: _________________________________________________________
Home Address: ________________________________________________________
Postal Address: ________________________________________________________
Email: ________________________________________________________________
Date of Birth: ________ /________ /________
Telephone: Home: ____________ Work: ____________ Mobile: ______________
Are you of Aboriginal or Torres Strait islander origin?  Yes  No  Prefer not to say
It is my wish that my remains, after death, be made available to the Discipline of Anatomy and Pathology at James Cook
University to be used in whatsoever way may be deemed most beneficial for the purposes of anatomical examination
or in the study, research, and teaching (including digital resources) of anatomy.
I consent to my remains being retained indefinitely. I understand that I will be cremated and my ashes will be (please
tick one box only):
 Scattered at the memorial garden at Woongarra Crematorium, or
 Returned to the next of kin. In the event that my NOK is uncontactable, my ashes are to be scattered at the
memorial garden at Woongarra Crematorium.
I have discussed this decision with my next of kin. I understand that circumstances may make it impossible for the
University to accept my offer.
Signed: ________________________________ Date: __________________

WITNESSES
Please ensure that your signature is witnessed by TWO people.
Witness 1:
Signed: _______________________________ Date: _______________________
Full Name: __________________________________________________________
Address: ____________________________________________________________
___________________________________________________________________
Witness 2:
Signed: _______________________________ Date: _______________________
Full Name: __________________________________________________________
Address: ____________________________________________________________
MEDICAL HISTORY
Current medical conditions:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Previous surgeries and medical conditions:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Next of Kin
The next of kin is responsible for contacting the Human Bequest Coordinator at the time of death.
We recommend they be a spouse, relative, friend, neighbour etc. Generally, a solicitor or Public
Trustee is not suitable as they are unlikely to notify JCU in a reasonable time.
I/We the undersigned SENIOR NEXT OF KIN of the above, have NO objection to his/her wishes
as stated above. I have read through the Information form and understand how the Body Donation
Program works. I am aware that circumstances may make it impossible for the University to
accept the donation at time of death and I acknowledge that alternative arrangements may need to
be made by the Donor’s family.
1. Name: (Mr/Mrs/Miss/Ms/Dr) _____________________________________________

Surname Given Names
Home Address: _______________________________________________________
Postal Address: _______________________________________________________
Email: ________________________________________________________________
Telephone: Home: _____________ Work: _____________ Mobile: _______________
Signed: __________________________ Relationship to Donor: _________________
2. Name: (Mr/Mrs/Miss/Ms/Dr) _____________________________________________

Surname Given Names
Home Address: _______________________________________________________
Postal Address: _______________________________________________________
Email: ________________________________________________________________
Telephone: Home: _____________ Work: _____________ Mobile: _______________
Signed: __________________________ Relationship to Donor: _________________
A Thanksgiving Service is held regularly and relatives of those who have donated their bodies to
medical science will be invited, together with members of the University staff and health students.
Please indicate if you wish to be notified (please tick one box only):
 I wish to be notified of the University Thanksgiving Service

 I do not wish to be notified of the University Thanksgiving Service
Townsville Campus
Townsville Qld 4811
Australia
www.jcu.edu.au
CRICOS Provider Code
00117J
College of Medicine & Dentistry

Telephone (07) 4781 5022
International +61 7 4781 5022
Email: humanbequest.coordinator@jcu.edu.au
AUTHORITY TO RELEASE
I, of:
(NOK Name) (NOK Address)
(Address continued)
Being the senior available next of kin, authorise the following:

1. Consent for the release of medical information to assist in Human Bequest registrant
screening process
2. Funeral Transfer Service nominated by James Cook University collection and transfer of:
The late
(name of Deceased Donor)
From:_________________________________________________________________
(to be completed at time of death)
To: Discipline of Anatomy, College of Medicine & Dentistry, James Cook University, Townsville.
NOK Signed: _______________________________________________
NOK Print Name: ____________________________________________
NOK Relationship to Deceased: _________________________________
Please have your next of kin (NOK) complete this ‘Authority to Release’ form (leaving the ‘from’
section BLANK). We require this form to be on file with the consent form at the time of registration
as this is often difficult for the next of kin to complete at the time of the donor’s passing, and is
required for transfer.

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THIS FORM IS SUPPLIED FOR THE CONVENIENCE OF DONORS AND IS IN NO WAY

Donor Consent Form

Surname: (Mr/Mrs/Miss/Ms/Dr) ____________________________________________

Given Names: _________________________________________________________

Home Address: ________________________________________________________

Postal Address: ________________________________________________________

Date of Birth: ________ /________ /________

Telephone: Home: ____________ Work: ____________ Mobile: ______________

 Scattered at the memorial garden at Woongarra Crematorium, or

Signed: ________________________________ Date: __________________

Signed: _______________________________ Date: _______________________

Full Name: __________________________________________________________

Signed: _______________________________ Date: _______________________

Full Name: __________________________________________________________

Previous surgeries and medical conditions:

1. Name: (Mr/Mrs/Miss/Ms/Dr) _____________________________________________

Home Address: _______________________________________________________

Postal Address: _______________________________________________________

Telephone: Home: _____________ Work: _____________ Mobile: _______________

Signed: __________________________ Relationship to Donor: _________________

2. Name: (Mr/Mrs/Miss/Ms/Dr) _____________________________________________

Home Address: _______________________________________________________

Postal Address: _______________________________________________________

Telephone: Home: _____________ Work: _____________ Mobile: _______________

Signed: __________________________ Relationship to Donor: _________________

 I wish to be notified of the University Thanksgiving Service

College of Medicine & Dentistry

Being the senior available next of kin, authorise the following:

NOK Signed: _______________________________________________

NOK Print Name: ____________________________________________

NOK Relationship to Deceased: _________________________________

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Date of Birth: / /

Telephone: Home: Work: Mobile: __

Signed: ______________ Date:

Signed: _________ Date: _

Signed: _________ Date: _

Telephone: Home: _______ Work: _ Mobile: _________

Signed: __________ Relationship to Donor: _

Telephone: Home: _______ Work: _ Mobile: _________

Signed: __________ Relationship to Donor: _