Consent for Autopsy and Donation of Brain Tissue
› This form acts as your consent for donation of postmortem brain tissue for research purposes. This form must be completed by the patient / family and must travel with the body for use by the pathologist and for their records. The pathologist will ship this form along with the brain tissue and the autopsy information form they complete( next page).
› Please note that it is likely that the pathologist will also have their own consent or other paperwork for you to complete in advance or at the time of brain donation.
Name of patient: ___________________________________________________ Date of birth: _______________________
Name of healthcare power of attorney / next of kin: ________________________________________________________ Relationship to patient: _________________________________________________________________________________ Address: _________________________________________________________________________________________________ City: _____________________________________ State / Province: _____ ZIP code: ____________ Country: ________ Phone: ___________________________________________ Email: _______________________________________________
Pathologist information: Name: ___________________________________________ Facility / Company: ___________________________________ Address: _________________________________________________________________________________________________ City: _____________________________________ State / Province: _____ ZIP code: ____________ Country: ________ Phone: ___________________________________________ Email: _______________________________________________
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Funeral / mortuary / body donation service: Name of Company: ________________________________________________________________________________________ Address: _________________________________________________________________________________________________ City: _____________________________________ State / Province: _____ ZIP code: ____________ Country: ________ Name of primary contact person: ______________________________________________________________________________ Phone: ___________________________________________ Email: _______________________________________________
In capacity and as signer of this autopsy permit, I / we do hereby direct that postmortem brain tissue from the autopsy of __________________________________________________( name of patient), ______________( date of birth), be procured by the agreed upon pathologist( as listed above and on page 14), out of the agreed upon location and, if applicable, in collaboration with the above-listed mortuary service, and shipped and donated to the Mayo Clinic Brain Bank for special studies and research on neurodegeneration diseases through the CurePSP Brain Donation Assistance Program.
Signature of patient or authorized patient representative: Circle one: patient, healthcare power of attorney, next-of-kin, or witness ____________________________________________________________________________________ Date: ________________