Pre-Screening Form


The purpose of this form is to provide pre-screening for whole body science donation and FREE cremation.

The results of this pre-screening are intended to provide a confidential evaluation of whether the prospective donor qualifies for whole body donation.

COMPLETING THIS FORM DOES NOT GUARANTEE ACCEPTANCE INTO DONATION TO THE SCIENCE PROGRAM NOR FREE CREMATION.

INSTEAD, THIS FORM IS INTENDED TO PROVIDE A NON-BINDING PRELIMINARY EVALUATION OF THE POSSIBILITY OF THE PROSPECTIVE DONOR'S ACCEPTANCE INTO THE PROGRAM.

Please attempt to answer each question to the best of your knowledge and belief.


This question is required
This question is required
This question is required
Please enter 999-999-9999 if the telephone number is not known
This question is required
Please enter 999-999-9999 if the telephone number is not known
If the prospective donor cannot receive mail, please provide your address
This question is required
If the prospective donor cannot receive mail, please provide your address
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Please enter a valid date
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Please choose an answer

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