Wise Health System

Wise Health System invites you to become a lifesaver!

By joining the Donate Life Texas donor registry, you give hope to thousands of people awaiting the transplant they need to survive.
Registering to become an organ, eye and tissue donor records your decision to be a donor. Your generosity can save as many as eight
lives through organ donation and bring sight and healing to another 75 people or more through cornea & tissue donation.

It takes only moments, yet means a second chance of a lifetime.

Spread the word

https://www.donatelifetexas.org/whs/

Register as a donor

Gender*

male female

First Name*

Middle Name

Last Name*

Date of Birth (ex: MM/DD/YYYY)*

Most Recent Address*

City*

State*

Not from Texas? Visit Donate Life America to find the registry for your state.

ZIP Code*

Phone

E-mail Address*

Place of Birth (City, State)

Ethnicity

PLEASE PROVIDE ONE OF THE FOLLOWING:

SSN# (Last Four Digits)

Texas Driver License/Personal ID:

Mother's Maiden Name

How did you learn about the Texas Donor Registry?

Please Specify

I would like to donate:

all organs and tissues for transplant and for research, education or therapy purposes if they are determined unsuitable for transplant
all organs and tissues for transplant only
to specify my gift of donation on the next page

Have you signed up for a Body Donation Program? If so, please indicate which program:

Electronic Signature Certification
I understand this online registration remains binding after my death. I do solemnly swear, affirm or certify that I am the applicant described in application, and that the information entered herein is true and correct. By clicking the submit button I affirm that I wish to be a potential organ donor and/or tissue donor upon my death.

Yes, I accept the Electronic Signature Certification.

Wise Health System

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