Tissue Order Form

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Surgeon Name*
First Last
Phone*
Assistant/Coordinator Name
First Last
Surgery Date*
MM slash DD slash YYYY
Surgery Time*

: Hours

Minutes

AM/PM
Surgery Location*
Type of Surgery*
Diagnostic Code*
NOTE: “Tissue rejection” does not include primary graft failure, microbial / infectious, vitreousendothelial touch, intraoperative trauma, glaucoma, refractive abnormalities, or failure of endothelial keratoplasty to adhere.

PK = Penetrating Keratoplasty, EK = Endothelial Keratoplasty (e.g. DSEK, DSAEK, DMEK, DMAEK, etc.), ALK = anterior lamellar keratoplasty, RK = Radial Keratotomy, HK = Hexagonal Keratotomy, PRK = photorefractive keratectomy, LASIK = Laser-assisted Keratomileusis, LASEK = Laser-assisted Sub-epithelial Keratectomy
Please Describe Type of Surgery
Type of Tissue*
Please Describe Type of Tissue (specifications)
Eye Involved*
Patient Name*
First Last
Patient DOB*
Month
Day
Year
Patient SSN*
Patient Address*
Street Address City State / Province / Region ZIP / Postal Code
Purchase Order Number

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