* Required fields.
Recipient Name *
Date of Birth * (mm/dd/yyyy)
Unique Identifications Type *
-- SELECT ID Type --
Social Security Number
Other Government Issued Number
Medical Record Number
Other (list type)
Unique Identifications Number *
-- SELECT Race --
Asian / Pacific
-- SELECT Gender --
Medical ID *
Transplant Procedure *
SELECT Transplant Procedure
Glaucoma Patch/Shunt Cover -- FRESH
Glaucoma Patch/Shunt Cover - Long-term Preserved
Keratolimbal Allograft / Stem Cells
Endothelial Keratoplasty (Ultra-thin: 50-90 microns, avail in USA only)
Anterior Lamellar Keratoplasty/Lamellar Keratoplasty
IntraLase-Enabled Keratoplasty (PRE-SECTIONED)
IntraLase-Enabled Keratoplasty (NOT PRE-SECTIONED)
DMEK (pre-sectioned, with S stamp)
DMEK (pre-sectioned, NO S STAMP
Endothelial Keratoplasty (NOT PRE-SECTIONED)
Endothelial Keratoplasty Standard, pre-sectioned (100 microns or greater)
Endothelial Keratoplasty Ultra-thin, pre-sectioned. (50-80 microns)
Sclera (whole only)
Other(specify and choose the best diagnosis/indication below)
Pre-sectioned EK tissue desired thickness in microns
Please Note: Tissue Choices have been updated and now offer the choice of pre-sectioned tissues for Endothelial Keratoplasties and Intralase Enabled Keratoplasties.
The Rocky Mountain Lions Eye Bank offers pre-sectioned corneal tissue for endothelial keratoplasty or anterior lamellar keratoplasty. Locally recovered corneas are sectioned in-house and are available as a standard graft of greater than 100 microns and an ultra-thin graft that is between 50-90 microns. Ultra-thin grafts are available for U.S. surgery locations only.
Tissue for IntraLase-Enabled Keratoplasty is also available. Both types of pre-sectioned tissue is prepared in compliance with applicable governmental and FDA laws and regulations relating to the procurement, storage, processing and distribution of human tissue. The tissue is prepared according to Good Tissue Practices (GTPs) in a dedicated procedures room.
The process adds only two days to the tissue placement process, so surgeries scheduled according to our scheduling policy (no more than 6 weeks in advance) can easily be accommodated. Please note that pre-sectioned tissues carry additional fees and cannot be returned to the eye bank.
Pre Operative Diagnosis/Indication for Transplant *
(pick list any of the following)
Ulcerative keratitis or Perforation
Unspecified anterior stromal scarring
Post refractive surgery
Post-cataract surgery edema
Repeat corneal transplant
Other degenerations or dystrophies
Mechanical or chemical trauma (non-surgical)
Other causes of corneal opacity or distortion
Post-cataract surgery edema
Other causes, cornea opacification/distortion
Repeat corneal endothelial transplant
Name of Surgeon *
Name of Surgery Institution *
Surgery Date * (mm/dd/yyyy)
Surgery Time (mm:hh AM/PM)
Surgery Phone *
Surgery Fax *
Purchase Order Num (if applicable)
Information Completed by Surgical Coordinator:
Copyright © 2018 Rocky Mountain Lions Eye Bank All Rights Reserved.
*All form fields are required.
New Users Subscribe Here!
You have been successfully logged in!
Sorry there was a problem logging you in.
You do not have access to this secure page.
If you think that this is in error, please check with the site administrator. (ID = 29)