UNT Health Science Center Willed Body Program

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Willed Body Consent Form

This form is to be completed by individuals who intend to become a member of the UNT Health Science Center's Willed Body Program. It consists of approximately 50 questions and could take up to 30 minutes to complete. It is possible to save your progress and return later to complete the form. If you have living relatives you will need to provide their contact information. 25 of the questions are related to medical history.

In providing my full name and social security number below, I assert that I am of sound mind and disposition, and desire to be of service to my fellow man, do hereby donate and bequeath my body upon my death to be used, in whatever manner appropriate, for the training of medical personnel and the advancement of medical science through education and research.


I further direct that my next of kin or Executor immediately telephone the Willed Body Program at UNT Health Science Center, Fort Worth, at 817-304-3763, to arrange for removal of my unembalmed remains.


I authorize the Anatomical Board of the State of Texas, to transport the willed/donated body herein described out of the state of Texas in the event that the holding institution and the Executive Secretary of the Board have determined that an excess of bodies for scientific uses currently exists in the State of Texas


It is understood that the Willed Body Program at UNT Health Science Center will transport and prepare the remains, if acceptable, for medical education and research.


I understand that UNT Health Science Center reserves the right to decline a body that has been embalmed. In addition, I understand that I cannot be guaranteed that my body will be accepted at the time of death. If I am morbidly obese, emaciated, or have a contagious disease (e.g. HIV, Hepatitis, active TB, etc.), if an independent autopsy is performed, my body may not be accepted by the Willed Body Program. If the Willed Body Program is unable to use my body for these or other reasons, my survivors will need to make other arrangements for the final disposition of my body, and the Willed Body Program is not responsible for any costs associated with other arrangements.


I hereby relinquish all rights and claims regarding herein described body, by any person whatsoever, and direct that in accepting and using this body for scientific purposes, and disposing of the body, neither the Anatomical Board of the State of Texas nor the receiving institution shall incur any liability, and no claim shall arise against that institution in any manner.


Complaints or inquiries regarding, a willed or donated body should be directed to the Secretary-Treasurer of the Anatomical Board of the State of Texas. The name and address of this individual may be obtained from the institution to which the body was delivered.

Provide your full name as your signature acknowledging and agreeing to the above paragraph.*
Your Mother's Maiden Name*
Address*

With few exceptions, you are entitled on your request to be informed about the information UNT Health Science Center collects about you. Under Section 552.021 and 552.03 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have UNT Health Science Center correct information about you that is held by us and that is incorrect. The information that the UNT Health Science Center collects will be retained and maintained as required by Texas records retention laws (Section 441.180, et. Seq. of the Texas Government Code) and rules.

Social Demographics

Gender*
Ethnicity*
Date of Birth*
Marital Status*
Education*
Please do not list "retired", it is not accepted as an occupation.
Were you a U.S. Veteran?*

UNT Health Science Center - Willed Body Program Death Certificate

Legal Name of Deceased (include AKA's if any)*
Is this form being completed before or after death?*
Date of Death (actual or presumed)*
Gender*
Date of Birth*
Marital status at time of death*
Decedent's Residence at time of death*
Name of Decedent's Mother. (Please use MAIDEN name)*
Name of Decedent's Father*
Did death occur in a hospital?*
Was in an "In Patient" or "ER/Outpatient" facility?*
Where did death occur?
Address for location of death (provide facility name)*
Decedent's level of education*
Ethnicity*
Was the deceased ever in the U.S. armed forces?*
Was the deceased ever a peace officer in the state of Texas?
Please do not list "retired", it is not accepted as an occupation.
Name of Informant completing this death certificate.*
Informant's address*
Date of "Willed Body Death Certificate" completion*

Next of Kin and Parents

Please provide at least one contact, preferably Next-of-Kin.

Next of Kin*
Next of Kin Address*
Second Next of Kin
Second Next of Kin Address
Name of Donor or Member's Mother*
Name of Donor or Member Father*

UNT Health Science Center - Body Donation Consent Form

I am the next-of-kin of the recently deceased named below, and I do hereby give and grant their body to UNT Health Science Center for medical teaching and research purposes. I do hereby direct the Willed Body Program at UNT Health Science Center, Fort Worth, 817-735-2043 to deliver the unembalmed remains to the Anatomical Board of Texas at UNT Health Science Center. I do hereby relinquish all rights and claims to the body and do grant unto the said medical school full rights to use said body for medical teaching and research purposes and ultimately to dispose of the body by cremation.

Check this box if you've read and agree with the above paragraph.*

I authorize the Anatomical Board of the State of Texas to transport the willed/donated body herein described out of the State of Texas in the event that the holding institution and the Executive Secretary of the Board have determined that an excess of bodies for scientific uses currently exists in the state of Texas.

 In accepting and using this body for the prescribed purposes, and disposing of the body, I relinquish all rights and claims regarding hereon described body, by any person whatsoever, and direct that in accepting and using this body for scientific purposes, and disposing of the body, neither the Anatomical Board of the state nor the receiving institution shall incur any liability, and no claim shall rise against that institution in any manner.

Check this box if you've read and agree with the above paragraph.*

Complaints or inquiries regarding a willed or donated body should be directed to the Secretary-Treasurer of the Anatomical Board of the State of Texas. The name and address of this individual may be obtained from the institution to which the body was delivered.

Name of Donor, Next-of-Kin, or person acting as such*
Address of Donor, Next-of-Kin, or person acting as such*

Cremains Directive

Are the cremated remains to be returned?*

If cremated remains are to be returned, the recipient will be contacted by letter prior to delivery. This is usually 18 to 24 months. It may not be possible to comply if the request is made at a later date or if the cremated remains are not available because of the nature of the medical research.

Recipient's Name*
Recipient's Address*

Medical History 1/3

Donor or Member's Name*
Name of person completing the form for Donor or Member:*

Note: The person completing this form should answer ALL questions either YES or NO, to the best of your knowledge. Please comment and elaborate on all questions marked YES.

Do you feel you know the Donor / Member well enough to answer questions regarding their medical and social history?*
Gender of Donor*
Has he/she been treated by a physician in the past two years?*
Has he/she been hospitalized in the past two years?*
Please list any diagnosed illnesses
Did he/she have any serious illnesses or infections in the past?*
Did he/she have any surgical procedures in the past?*
Has he/she ever been diagnosed with any of the following contagious illnesses?*
Did he/she ever use non-prescribed drugs, "street" drugs or other substances, such as cocaine, marijuana, steroids, inhalants, heroin?*
Did he/she ever drink alcoholic beverages?*
Did he/she ever use tobacco products?*

Medical History Continued (2/3)

Did he/she ever receive blood transfusions or blood products?*
Was he/she ever refused as a blood donor or told not to donate?*
Has the donor had a history of blood clots in the legs?*
In the past 12 months did he/she have any of the following?*
Was he/she vaccinated or immunized for any reason in the past twelve months?*
Was he/she ever vaccinated for Hepatitis B?*
Did he/she have any history of the following?*
Did he/she have any kidney related disease(s) and/or dialysis treatments?*
Did he/she have a history of diabetes?*
Did he/she have a history of the following:*

Medical History Continued 3/3

Has he/she ever had cancer (including skin cancer)?*
Has he/she ever been diagnosed with any type of autoimmune disease?*
Did he/she have a medical diagnosis of:*
Did he/she have a history of skin infections such as leprosy, eczema, dermatitis, psoriasis, or inflammatory skin diseases?*
In the past twelve months has he/she ever been treated for any sexually transmitted disease such as syphilis, gonorrhea, genital herpes, or veneral warts?*
Has he/she ever been an inmate (confined to lockup, jail, or prison) for an extended period of time?*
Did he/she have a history of diseases, infections, or surgeries involving the eyes such as glaucoma, cataracts, corneal disease, refractive surgery, and/or laser surgery?*
FOR FEMALE DONORS ONLY: Has she ever had any of the following?*
Did he/she suffer from any type of neurological or brain disease such as:*
If he/she is accepted for this research would you be willing to receive a follow-up call from the Neurological or Psychiatric Research Department?*
Has (he/she) been evaluated for Autism Spectrum Disorder (ASD) or any related condition?*
Has (he/she) or a family member received the result of a genetic test that indicated a known genetic condition?*

Verification of Medical History


Please provide your full name in the next field as your signature attesting that, within your ability, you have disclosed the most complete and accurate medical history of the individual being donated.

Signature attesting to medical History*
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