Request Ocular Tissue

The Vision Share Distribution Center is on call 24 hours a day, 7 days a week, every day of the year.

  • Vision Share coordinates the distribution of ocular tissue throughout the U.S. and around the world.
  • Our highly trained distribution coordinators are committed to personalized quality service.
  • Vision Share continuously monitors processing outcomes and shipping details in order to ensure accuracy and efficiency.

Click for Downloadable Form (U.S. Only)    |    Fax form to 888-657-4410

Please complete the Patient Information in full, as it is required by EBAA Medical Standards.

Click 'SUBMIT' when completed.

    ONLINE ORDER TISSUE FORM
    Please complete the Patient Information in full, as it is required by EBAA Medical Standards.
    * Requesting Surgeon
    * Date of Surgery
    * Time of Surgery
    [time* surgery-time time-format:hh:mmtt step-minute:15 class:input]

    * Recipient Name
    * Date of Birth
    * Age
    * SSN/MRN#
    * EBAA Diagnosis
    Please Specify
    OSOD

    * Tissue Type

    * Please SpecifyGlycerolEthyl
    1/2Whole
    * Please Specify 1/41/2Whole
    * Please Specify1.5 x 1.02.0 x 1.52.5 x 2.03.5 x 3.55.0 x 5.0
    * Is custom eye bank processed tissue requested?YesNo
    If YES, Please specify.
    DSAEKDMEKDMAEK
    * Is custom eye bank processed tissue requested?YesNo
    * Our distribution department will send FS-LAK parameter form to email address provided below.
    Please List any Specifications or Special Requests

    Requester to Complete the Following
    * Name of Surgery Location
    * Surgery Location Address
    * Request Submitted By
    * Requester's Email Address (A form copy will be sent to this address)
    * Requester's Phone Number
    Requester's Fax Number
    Purchase Order

    captcha

    If request is placed with in 48 hours of surgery, please call 888-657-4448 to ensure we have received your request.

    Click for Downloadable Form    |    Fax form to 888-657-4410

    Click 'SUBMIT' when completed.

      CONTACT INFORMATION

      Organization Name

      Principle Researcher’s name

      Contact Person

      Email

      Phone

      Fax


      SHIPPING INFORMATION

      Facility Name

      Delivery Address

      Special Instructions


      BILLING INFORMATION


      Billing Contact

      Billing Address:

      Phone:

      Fax:

      P.O #:


      RESEARCH DATA
      Summarize project(s) that will utilize tissue or attach an existing description:


      TISSUE INFORMATION

      Tissue Type:
      CorneaWhole GlobesPosterior Poles

      Amount Desired:

      Will these be distributed to anyone else:
      YesNo

      Donor Age Criteria:

      Prior ocular surgery acceptable?
      YesNo

      Conditions not allowed (e.g. diabetes, sepsis, chemo):

      Serology Needed:
      YesNo
      (additional charge applies)

      Does sterile technique need to be maintained:
      YesNo

      Preservation Method:

      Other Criteria:

      The above statements are true; the tissue requested will be used only for the purposes stated. It is understood that you are accepting full responsibility for this research tissue and you will use Universal Precautions when handling the tissue

      captcha

      If request is placed with in 48 hours of surgery, please call 888-657-4448 to ensure we have received your request.

      midwirelogo

      Midwire is a clinical information system for eye banking, developed by Midwire Systems. Midwire helps you to collect, protect, and manage essential information as you recover, evaluate and distribute human eye tissue for transplantation.

      Visit Midwire

      If you do not have access to Midwire and are in need of tissue please contact:

      Vision Share Distribution Center
      Phone: 1-888-657-4448
      Email:  dc@visionshare.org
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