Save the Date

Join us in celebrating our 50th anniversary at the annual Eye Ball on September 9, 2023

Surgeon Registration Form

Register Your Tissue Preferences Below

Register your parameters for each type of procedure. Your online account will be set-up with this information and serve as a reference for your tissue requests. Some cases may require a unique set of specifications which can be included on the individual request.

Contact Information
Surgeon Name*
Surgeon Email*
Surgeon DOB M/D/Y*
Month
Day
Year
OK to contact surgeon? Select all that apply.
- After hours
- On Weekends
- By Text
Cell Number*
Average Transplants Performed Monthly*
Surgery Days
- M
- T
- W
- TH
- F
Practice Name**
Address*
City
State
Zip
Surgical Coordinator (requests tissue & receives tissue offers)
Preferred Method of Contact
- Email
- Phone
- Cell
- Fax
Phone
Email*
Cell
Fax
Surgeon Facility No.1
Space for additional surgical facilities listed below.
Surgical Facility Name**
Delivery Address*
City
State
Zip
Phone
Fax
Contact Name*
Email*
Purchase Order Number Required?
- Yes
- No
Delivery Hours
Billing Address if different than Delivery
City
State
Zip
Tissue Offer Preferences
Maximum Death to Preservation Time (in hours)
Maximum Death to Surgery Time (in days)
Exclusionary Criteria
Minimum Cell Density
PKP DSAEK / UT DSAEK DMEK
Minimum Donor Age
PKP DSAEK / UT DSAEK DMEK
Maximum Donor Age
PKP DSAEK / UT DSAEK DMEK
Other Types of Surgeries Performed
Tissue Processing Preferences – Ampho B:
- Yes
- No
DSAEK
DSAEK Thickness Range
- Ultrathin 40-70 µm*
- Ultrathin 71-99 µm
- Traditional 100+ µm
Target Thickness Processing capabilities are ± 25 μm of requested target.
Preloaded:
- Yes
- No
Prestained:
- Yes
- No
Non-Preloaded DSAEK Orientation Marking Options:
- 1. Central dot on cap for cornea centration
- 2. "S" mark on stromal side of the graft
- 3. Turtle Markings
- 4. No Markings
DSAEK Preloaded Options:
Preferred preloaded device:
- Weiss Glass Cannula – LWVI 2.8*
- DSAEK Endoglide
Graft Size (in mm)
- 7.00
- 7.25
- 7.50
- 7.75
- 8.00
- 8.25
- 8.50
- 8.75
Additional Options:
- "S" Stamp on stromal side of graft*
- Stain*
- Scleral rim for culture
*Recommended specs for preloaded DSAEK: 40-70 μm, stain, and “S” stamp
DMEK
Prestained:
- Yes
- No
Prepunched
- Yes
- No
Preloaded:
- Yes
- No
- Scleral rim for culture
If PRELOADED, choose preferred device below:
- Preloaded in Weiss Glass Cannula – LWVI 1.6
- Preloaded in Weiss Glass Cannula – STRAIKO
- Preloaded in DMEK EndoGlide
If prepunched or preloaded, include graft size (in mm)
- 7.00
- 7.25
- 7.50
- 7.75
- 8.00
- 8.25
- 8.50
DMEK Orientation Marking Options
- I-II (Anterior View) Prepunched, preloaded option only
- "S" Stamp (Anterior View)
- No Markings
Enter additional facilities below or scroll down to submit registration
Surgeon Facility No.2
Facility Name
Address
City
State
Zip
Phone
Fax
Contact Name
Email
Purchase Order Number Required?
- Yes
- No
Delivery Hours
Billing Address if different than Delivery
City
State
Zip
Surgeon Facility No.3
Facility Name
Address
City
State
Zip
Phone
Fax
Contact Name
Email
Purchase Order Number Required?
- Yes
- No
Delivery Hours
Billing Address if different than Delivery
City
State
Zip
Surgeon Facility No.4
Facility Name
Address
City
State
Zip
Phone
Fax
Contact Name
Email
Purchase Order Number Required?
- Yes
- No
Delivery Hours
Billing Address if different than Delivery
City
State
Zip
Surgeon Facility No.5
Surgical Facility Name
Delivery Address
Delivery Address City State / Province / Region ZIP / Postal Code
Phone
Fax
Cell
Email
Contact Name
Purchase Order Number Required?
- Yes
- No
Delivery Hours
Billing Address (if different than Delivery)
Billing Address (if different than Delivery)
Street Address City State / Province / Region ZIP / Postal Code
Additional comments
Untitled
- First Choice
- Second Choice
- Third Choice

Save the Date

Surgeon Registration Form

Register Your Tissue Preferences Below

Contact Information

Surgeon Facility No.1

Tissue Offer Preferences

DSAEK

DSAEK Preloaded Options:

DMEK

Enter additional facilities below or scroll down to submit registration

Surgeon Facility No.2

Surgeon Facility No.3

Surgeon Facility No.4

Surgeon Facility No.5

Join Our Newsletter