Tissue Donation

Birth Tissue Donation Form

Did you know?

Birth tissue contains nutrients that stimulate the body’s own healing mechanism.
The placenta and other tissues are discarded after birth, yet they offer patients healing potential for the treatment of burns, wound healing and repair of soft tissue and tendons. These grafts can also reduce post-surgical complications while limiting the amount of scarring the patient would normally experience.
Each donation can help as many as 50 to 100 patients through every individual donation of birth tissue.

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Name*

First Last

Date of Birth*

Phone*

Email*

When is the best time to call?*

Morning

Afternoon

Evening

Due Date*

Delivery Hospital*

Delivery Method*

Additional Comments