Florida Lions Eye Bank
 

 


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Tissue Request Form

FLORIDA LIONS EYE BANK
900 NW 17th Street Miami, FL 33136
Tel: (305) 324-4340
fax1 (305) 547-3692 fax2: (305) 326-6376
flebdistribution@med.miami.edu
DATE OF REQUEST:

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DD
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YYYY
SURGERY LOCATION:
SURGERY DATE AND TIME:
SURGEON NAME:
CONTACT NAME:
EMAIL FOR CONFIRMATION:
PHONE:

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FAX:

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PATIENT INFORMATION

LAST NAME:
FIRST NAME:
DATE OF BIRTH:

MM
/
DD
/
YYYY
AGE:
SEX:
RACE:
ID # ( MR OR SS):
ADDRESS:
CITY:
STATE:
ZIP CODE:

DIAGNOSIS

SELECT DIAGNOSIS
 POST CATARACT SURGERY EDEMA 
 KERATOCONUS 
 FUCH’S DYSTROPHY 
 REPEAT CORNEAL TRANSPLANT 
 OTHER DEGENERATIONS OR DYSTROPHIES 
 POST REFRACTIVE SURGERY 
 MICROBIAL CHANGES 
 MECHANICAL OR CHEMICAL TRAUMA 
 CONGENITAL OPACITIES 
 PTERYGIUM 
 NON-INFECTIOUS ULCERATIVE KERATITIS OR PERFORATION 
 OTHER ENDOTHELIAL DYSFUNCTION 
 OTHER NON ENDOTHELIAL DYSFUNCTION 

SURGICAL PROCEDURE

SELECT SURGICAL PROCEDURE
 PKP (PENETRATING KERATOPLASTY) 
 DSAEK OR DLEK (DESCEMET STRIPPING OR DEEP LAMELLAR) 
 DMEK (DESCEMET MEMBRANE ENDOTHELIAL KERATOPLASTY) 
 DALK (DEEP ANTERIOR LAMELLAR) 
 SALK (SUPERFICIAL ANTERIOR LAMELLAR) 
 OTHER ALK (PERIPHERAL, ECCENTRIC, ETC.) 
 KLAL(KERATOLIMBAL ALLOGRAFT) 
 TECTONIC FULL THICKNESS 
 KERATOPROTHESIS (K-PRO) 
 GLAUCOMA SHUNT PATCH OR OTHER NON-KP USE 
 ENUCLEATION 
 OTHER 

REQUIRED TISSUE

TISSUE NEEDED
 CORNEA (OPTICAL) 
 CORNEA PATCH (THERAPEUTIC TECTONIC) 
 WHOLE GLOBE (MOIST CHAMBER) 
 DSAEK (Enter desired thickness below) 
GLYCERIN PRESERVED TISSUE
CORNEA SIZE:
 WHOLE FULL THICKNESS 
 HALF FULL THICKNESS 
 HALF SPLIT THICKNESS 
SCLERA SIZE:
 WHOLE 
 QUARTER (¼) 
 EIGHTH (⅛) 
SHIP TISSUE TO:
SHIP VIA:
BILL TO:
PO #:
F-054 V2.0
Florida Lions Eye Bank

Calendar of Events

October 24, Wednesday
6:00pm – 7:30pm
AWAY MEETING
Bascom Palmer Eye Institute
Naples, Florida

December 5, Wednesday
Nominating Committee Meeting
5:00pm – 6:00pm
Board of Directors Meeting
6:00pm – 7:30pm
Bascom Palmer Eye Institute
Miami, Florida

 

Contact Us

 

Florida Lions Eye Bank
900 NW 17th Street #348
Miami, FL 33136

 

Telephone: (305) 326-6359
Toll-free: (800) 329-7000 Ext. 6359

 

General Email: info@fleb.org

 

Distribution Email: FLEBDistribution@med.miami.edu

 

 

 

 

 

Mission


In the fight against visual impairment and blindness, the Florida Lions Eye Bank recovers, processes and distributes ocular tissue for sight-saving surgery. It provides eye tissue and funding for ophthalmic research and training and operates a pathology lab to assist with patient diagnosis and treatment. It also provides professional and community education to promote eye donation.




 

Cooperating Partners

 

Copyright © 2015
Florida Lions Eye Bank

All Rights Reserved

 

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