Adverse Reaction Form

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SURGERY INFORMATION
Surgeon Name*
First Last
Surgeon Email (optional)
Surgery Location*
Facility Name
RECIPIENT OUTCOME
Additional Surgery:*
If you answered "Other" above, please describe the additional procedure:*
Recent Vision:*
RECIPIENT INFORMATION
Patient Name*
First Last
Patient DOB*
Month
Day
Year
Patient SSN*
Patient Gender*
Pre-Op Diagnosis:*
Surgery Date*
MM slash DD slash YYYY
Procedure:*
ADVERSE REACTION
Date of Diagnosis*
MM slash DD slash YYYY
Cause*
Was donor tissue a cause?*
MICROBIOLOGY
Donor Cultures (Check applicable)*
- Preservation Media
- Cornescleral
- Other
- Not Done
Patient Cultures (Check applicable)*
- Aqueous
- Vitreous
- Cornea
- Other
- Not Done
By submitting this document you are attesting that you are the surgeon or designee, and all information in correct.

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SURGERY INFORMATION