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Transplant Recipient Form

These Fields are required:


    * Required fields.

    This form verifies that the human tissue referenced by the tissue ID number was transplanted to the patient indicated. For the safety of your patient, the Rocky Mountain Lions Eye Bank is required to collect this information by the U.S. Food and Drug Administration. Patient information remains confidential.

    Required Recipient Information

     

    Surgeon Information

    *Are there any tissue-related postoperative complications, positive donor rim/cornea/sclera/media cultures? If yes please describe. Yes or  No

     

    *Are there any tissue related recipient infections or adverse reactions? If yes please describe. Yes or  No

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