UtraxDonorRegistrationApplication

General Information

Fill out the general information

Demographic Information

Basic personal details of the donor

Eligibility Pre-Screen

Overview of Eligibility

Medical/Social History

Questions about the donor’s medical history

Next Steps and What to Expect

No internment plan? UTN can scatter your loved one’s ashes.

Final Step

You have reached the end of the process

General Information

Enter your history and personal details below. Help Video .

If you need assistance, please contact Donor Services at 877-738-6111, or email donorinfo@unitedtissue.org.

Is the donor in the states of Arizona, Florida, Nevada, Rhode Island, Connecticut, New Jersey, New York or Massachusetts?

Yes

Status of the donor

IMMINENT DONOR: Donor is currently receiving hospice or experiencing terminal illness with limited time remaining.

PASSED DONOR: Donor has passed away.

PLEDGE/FUTURE DONOR: Donor is currently living and interested in registering to donate their body to science after their passing

How Did You Hear About UTN?

Contact Information of the person completing this form

Full Legal Name

Street Address

City/Town

State

Zip

Phone Number

“By checking this box, you agree to receive SMS messages from United Tissue Network related to next steps in the donation process. You may reply “STOP” to opt-out at any time or reply “HELP” for assistance. Messages and data rates may apply. Message frequency will vary. Learn more on our Privacy Policy page.”

Relation to Donor

Donor Information - Information about the individual interested in whole-body donation.

First Name

Last Name

Donor address.

Same as previous

Street Address

City/Town

State

Zip

Date of Birth

Marital Status

Primary physician name

Primary physician number