Recipient Information Form




Attention :
Tissue ID# :
Please complete and click on send button as soon following the transplant.
This form verifies that the tissue reference was translanted to the patient indicated below.
SURGEON AND INSTITUTION:-
Surgery Location:
Surgeon:
Date Of Transplant:
RECIPIENT INFORMATION:-
Family Name:
Given Name:
Age:
DOB:
ID#:
Gender:
MR No.:
Email:
House no./ ward no:
City:
District:
Hobbies/Interestes:
Phone:
Occupation:
OPHTHALMIC HISTORY:(PLEASE USE DIAGNOSIS CODE LISTED IN THE ATTACHED FROM)
Eye Grafted:
Surgery Type:
Pre-Operative Diagnosis:
Previous Ocular Surgeries:
Spacial Concerns:
Surgery Sub Type:
PRE-OPERATIVE CHECKLIST
1. Is the tamper-evident seal on the tissue chamber or vial intact?
2. Does the graft number on the tissue label match the number on all accompany paper work ?
3. Is above recipient information correct ? if not, please correct.
4. Tissue evaluation acceptable ?
5. Indicate performance of steps 1-4 by signing below.
Upload Signature: