Surgery scheduling

Patient information

Female
Male

Surgeon information

Tissue requested

PKP
DMEK (processed by eye bank)
Punched
Pre-loaded
DMEK (processed by surgeon)
DSAEK (processed by eye bank)
Ultrathin
Pre-loaded (EndoGlide)
DSAEK (processed by surgeon)
ALK (processed by eye bank)
ALK (processed by surgeon)
DALK
Globes for KLA

K-Pro
LAK/IEK (processed by eye bank)
Other (please specify):

Sclera - whole
Sclera - half
Sclera - quarter
Sclera - eighth
6mm disc
Other (please specify):

Complete form

For questions contact Tissue Placement:
P: (866) 900-8119 • F: (734) 780-2730 • distribution@eversightvision.org

For emergency surgical requests, an Eversight representative is always available. Call the Tissue Placement hotline at (866) 900-8119.