Tissue Request Form

Tissue Requested: Tissue Requested: Cornea for PKP Cornea for KPro of Tectonic Graft Cornea for DALK or ALK Cornea for DSAEK Long-Term Preserved Tissue DMEK Capsule (Pre-loaded for DMEK) Cornea Pre-Peeled for DMEK

DSAEK Selection DSAEK Selection 4 Stromal Edge Marks Central Epithelial Dot S Mark Other

Sclera Size Sclera Size Whole 1/2 1/4 1/8

Cornea Size Cornea Size Whole 1/2 5 x 10

Thickness Thickness Full Split

Injector Size Injector Size 2.00mm 2.4-3.0mm

Graft Size Graft Size 7.0mm 7.5mm 8.0mm Other

Custom Graft Size

Mark Mark S Mark F Mark None

Preferred Hinge Preferred Hinge Side Hinge Central Hinge No Preference

Mark Mark S Mark F Mark None

Thickness Required

Thickness Required

Other Criteria

Other Criteria

Surgeon

Contact Person

Phone

Email

Facility

Address

Phone

Surgery Date & Time

Patient

Date of Birth

Sex SexMF

MRN

Diagnosis

OD OS