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Whole Brain Donation Information Form

Thank you for your interest in becoming a potential whole brain donor at Michigan Medicine!

Once you have completed the initial information form below, you will be contacted within 24 business hours (excluding weekends and holidays) by the Brain Tumor Program Coordinator.

While timely planning is imperative for this process, this form is only used to inquire about more information regarding donations and does not automatically register the donor. Proper consent and coordination must take place in order for any donation to be accepted.

If you have unanswered questions, it is always best to contact your treatment team.

Thank you for your interest in leaving your legacy with Michigan Medicine by visiting Michigan Medicine’s Neuro-Oncology Post-mortem Whole Brain Donation information page!

**NOTE: This is separate from Michigan Medicine’s Brain Bank in the Department of Neurology**

Donation Information Form

Patient's Name:

Patient's Date of Birth

Is the patient a Michigan Medicine patient?

  Yes

  No

If yes, patient's MRN (if known):

If no, what organization/institution is treating the patient?

Patient's doctor:

Patient's diagnosis:

Are you the patient?

  Yes

  No

If no, what is your name and relation to the patient?

Name:

Relationship to patient:

Contact Phone number:

Contact Email address:

Best way to contact?

  Email

  Phone

  Either

Comments/Questions

 

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