Allograft Resources, a department of the UT Transplant Centera department of the UT Transplant CenterAllograft Resources

Sample Statement Regarding Anatomical Gifts

 

I, __________________________, of __________________________ County, Texas, make the following statement regarding anatomical gifts.

 

ANATOMICAL GIFT
I give such parts of my body to such individuals, institutions, or physicians, qualified to receive anatomical gifts under Section 4 of the Texas Anatomical Gift Act, as may be requested by such individuals, institutions, or physicians. I request that my personal representative or an authorized person make anatomical gifts in a manner consistent with my desires expressed in this statement, and I request that my next of kin respect my wishes.

 

PRIORITY OF DONATIONS
An anatomical gift that will be used in connection with the treatment of an imminently life threatening disorder shall take precedence over a gift of that part to any other donee. My personal representative or an authorized person shall make final determination of who is to receive any part if a conflict should arise.

 

ATTENDING PHYSICIAN
If my attending physician accepts an anatomical gift on behalf of a donee, that physician shall not participate in the procedure for removing or transplanting such part.

 

INSTRUCTIONS
If I have given any written instructions regarding the burial, cremation, or other disposition of my body, I direct that any donee take possession of my body subject to such instructions, if that donee has actual knowledge of such instructions. If there is any conflict between the statements made in this document and such instructions, my wishes regarding anatomical gifts shall take preference over my instructions regarding the disposition of my body.

 

COUNTERPARTS
I may be signing more than one statement regarding anatomical gifts. I intend that only signed documents be effective and that no effect shall be given to a photocopy or other reproduction of a signed document.

 

DEFINITIONS
The term "part," "physician," and "attending physician" have the same meaning as is given to these terms in the Texas Anatomical Gifts Act. The term "authorized person" means a person authorized to make donations under Section 3(b) of the Texas Anatomical Gifts Act in the order of priority provided in that Act.

 

EXPENSES
I make this gift on the condition that the gift be made at no expense to my estate or my family. All expenses or costs associated with the gift shall be borne by the donee or recipient or an individual or entity on the donee's or recipient's behalf.

 

Signed in the presence of the witnesses who have signed below this __________ day of ___________________________________, 20____.

 

STATE OF TEXAS
COUNTY OF __________________________

BEFORE ME, the undersigned authority, on this day personally appeared __________________________, and, known to me to be the declarant and witnesses whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, __________________________ declared to me and to the said witnesses in my presence that said instrument is her Statement Regarding Anatomical Gifts, and that she had willingly and voluntarily made and executed it as her free act and deed for the purposes therein expressed.

___________________________________
Witness
___________________________________
Witness

SUBSCRIBED AND SWORN TO BEFORE ME by the declarant and by the witnesses this __________ day of ___________________________________, 20_____.

______________________________
Notary Public, State of Texas