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

* 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
TOP