Eversight Services Forms 2016 | Page 5

EVERSIGHT SERVICES SURGEON FORMS SURGERY SCHEDULING INFORMATION Please return completed form to Eversight Tissue Placement using the contact information below. Patient name: _____________________________________________________________________________ Street address: ____________________________________________________________________________ City, State, Zip: __________________________________________________________________________ Telephone number: ______________________________________________________________________ Patient diagnosis: _____________________________________________________________________ Date of birth: ____________________ Sex: Male Female Patient identifier (ex. MRN, chart #, insurance ID):_________________________________________ Surgeon: _______________________________________________________________________________ Surgery location: _______________________________________________________________________ PO number (if required): _______________________________________________________________ Surgery date: ___________________ Surgery time: ___________________ Tissue being requested: ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ PKP DMEK (processed by eye bank) DMEK (processed by surgeon) DSAEK (processed by eye bank) ❐ ❐ Ultrathin ❐ ❐ Pre-loaded (EndoGlide) ❐ ❐ DSAEK (processed by surgeon) ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ ❐ Sclera - whole ❐ ❐ Sclera - half ❐ ❐ Sclera - quarter ❐ ❐ Sclera - eighth ❐ ❐ 6mm disc ❐ ❐ Other (please specify):___________________ ALK (processed by eye bank) ALK (processed by surgeon) DALK Globes for KLA Quanitity:________________ K-Pro LAK/IEK (processed by eye bank) Other (please specify): ________________________________________ Person completing form:________________________________________________________________ Contact email:______________________________________ or FAX:____________________________ *Revised February 16, 2017 Tissue Placement: [phone] • Fax [phone] • [email protected]