Brain Donation Registration Form

Thank you for becoming a Brain Donor!

We appreciate your commitment to become a brain donor with the Dystonia Brain Collective. Please provide the following information and submit this form to Dysphonia International. We will record your decision to be listed as a brain donor with the Harvard Brain Tissue Resource Center. In addition, you will receive a wallet card, along with contact information. The most important thing is to inform your next-of-kin of your decision to donate your brain to help impact research for spasmodic dysphonia and related voice disorders.

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Brain Donor Information

Name*
Address*
MM slash DD slash YYYY

Next-of-Kin Information

Name*
Address*

Treating Physician

Name
Address