Florida Lions Eye Bank
 

 




SPANISH

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:

MM
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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

March 30, Saturday
OPEN HOUSE
Bascom Palmer Eye Institute
Board of Directors Meeting
Member Appreciation Day
Election of 2019-2020 Officers

 

Contact Us

 

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

 

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

 

General Email: info@fleb.org

 

Distribution Email: FLEBDistribution@med.miami.edu

 

 

 

 

 

Mission


Florida Lions Eye Bank provides ophthalmic services to ophthalmologists and patients to assist with treatment and advances the field of ophthalmology through research and innovation for the betterment of humankind.




 

Cooperating Partners

 

Copyright © 2015
Florida Lions Eye Bank

All Rights Reserved

 

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