Katelyn Shove, child cornea recipient

"I have two brown
eyes now!"

Katelyn Shove
SightLife™ Cornea Transplant Recipient

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Tissue Request Form

If you prefer to print out the form, fill it out, and fax it back in, you can find our tissue order downloads here.


* Indicates required fields
Surgeon
  
First Name:
    *
Last Name:
    *
Contact Person
  
First Name:
    *
Last Name:
    *
Telephone:
    *
 
   Telephone number required for United States orders.
  International orders have option to enter the letters "n/a"
Email:
    *
 
   Email address required for International orders.
  United States orders have option to enter the letters "n/a"
Fax:
    *
Country:
    *
Patient
  
First Name:
   *
Last Name:
    *
Date of Birth:
    *
Age:
    *
Sex:
    *
Race:
   
  
SSN or
Med. Record #:
Patient ID:
    *
Address 1:
   
Address 2:
   
City:
   
State:
Region:
   
  
Zipcode:
Postal code:
   
Diagnosis:
    *
If 'Other' diagnosis please specify:
 
Eye involved: OS    OD   
 
Please select one: Cornea    Whole Globe   
Sclera:    1/4    1/2    Whole
 
Transplant Procedure: PKP    LKP    DLKP    KLAL   
Endothelial Keratoplasty (EK, DLEK, DSEK, PLK)   
Other 
 
To order tissue for IEK™, please download and fill out the appropriate form:
  » Domestic (US) Custom Corneal Tissue™
» International Custom Corneal Tissue™
 


Requested Surgery Date:   *
Time of Surgery (approx):
Date of Arrival (at airport):
    *
Except for emergencies, please try to give at least 7 days notice
Except for emergencies, please try to give at least 10 days notice
Name of Surgery Facility:    *
Ship Tissue To (if different from above):   
 
Special Concerns
(multiple graft failures, age, blood typing, pre-cut, other): 		  
Purchase Order Number (if applicable):   
 


Emergency #: 888-266-4466, ask for SightLife Coordinator.

  1. Please submit request at least 7 days prior to the requested surgical date. The waiting list will be filled as the orders are received.
    Please submit request at least 10 days prior to the requested surgical date. The waiting list will be filled as the orders are received.
  2. Please notify the Eye Bank of any schedule changes by calling us (888-266-4466) or e-mailing us: .
  3. Emergent / urgent requests should be phoned directly to a SightLife Coordinator, (888-266-4466), and then followed up with a Tissue Request Form. If your office requires a confirmation fax or email back, please check the appropriate box below, and provide your fax number or email address.
Fax confirmation?       Fax number:
Email confirmation?       Email: