Patient information Please leave this field empty. 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.
