The National Repository Centre

Postgraduate Education Centre

City Hospital Campus
Hucknall Road
Nottingham
NG5 1PB

Tel: 0115 993 4988

Direct Line: 0115 962 7683
Mobile: 07812 268058
Email: Mark.Curwood@nuh.nhs.uk
www.nuh.nhs.uk
Body
Bequest Form
Human Tissue Act 2004

To be completed by person making the donation. Please complete in

BLOCK CAPITALS

Title Surname/Family name

Forename(s)

Address

Postcode Contact Tel

Date of birth

Occupation_______________________________________(Previous Occupation if Retired)

Religion/faith group
(If not applicable please mark as ‘None’)

I wish to donate my body after my death; I understand that it may be used

for medical education, training or research relating to human health and the
advancement of medical education.

 I consent to the use of images of my body or body parts

(*see explanatory note below).

*I understand that I will not be identifiable in these images and that they will be
used for Education, training or research relating to human health only. **Please
see footnote
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I understand that this consent includes permission to use my body for

medical education. It also includes permission to obtain blood specimens
for required testing. In addition this consent includes permission for the
release of my medical records to assist with medical education and to
determine the suitability of tissue. I understand that my identity will remain
confidential.

I understand that body parts may be removed, processed and sent to other
licensed centres. Small samples or pieces of tissue may be retained by
other centres and disposed of sensitively in accordance with local
procedures, larger body parts such as limbs, will be returned to the
Repository to be reunited with my body prior to the funeral.

I understand that this consent also transfers custodianship of my body

(after death) to the National Repository to permit funeral arrangements to be
made as stated below (a OR b).

Please tick as appropriate

1.  I do not place any restrictions on the length of time that my body or

body parts may be retained

Or

2.  My body can be retained for a maximum of 2 years only.

Instructions on the disposal of the Bequeathed body

Please specify your wishes for the disposal of your body below. Please tick as
appropriate.

a. Cremation with arrangements made by the Repository Centre 

OR
b. Private Funeral arrangements made by next of kin or executor 

The National Repository Centre reserves the right to decline acceptance, for any reason of your
body after death. If the centre declines to accept your body it will not be responsible in any way
for your funeral arrangements or the costs associated therewith. We strongly advise that you
and your next of kin put alternative
arrangements in place should the centre be unable to accept your
body at the time of your death.
Page 2 of 3

Declaration

Donor signature Date

Witness declaration

I confirm that I have witnessed (insert name of

donor) completing the above form.

Title Surname/Family name

Forename(s)

Address

Postcode Contact Tel:

Relationship to donor

Signed Date

**Footnote
The taking and displaying of images (including photographs, films and electronic
images) is outside the scope of the Human Tissue Act 2004; however, the HTA
endorses the good practice principles set out in guidance issued by relevant
professional and regulatory bodies. For further Information, please refer to the
HTA’s Codes of Practice, available at www.hta.gov.uk

NNRC / Bequeathal Consent / NUH-004/NNRC-L2-v4

Date Issued: January 2013
Date Reviewed: 14/05/2018
Date of Revision: May 2019
Approved by: Rebekah Hudson
National Repository © February 2015.
All rights reserved. Nottingham University Hospitals NHS Trust.
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