:: EYE BANK ::

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:

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?

Yes

No

2. Does the graft number on the tissue label match the number on all accompany paper work ?

Yes

No

3. Is above recipient information correct ? if not, please correct.

Yes

No

4. Tissue evaluation acceptable ?

Yes

No

5. Indicate performance of steps 1-4 by signing below.

Yes

No

Upload Signature:

Recipient Information Form