Application and Request for Gratis Tissue

If you are a physician or a medical facility seeking gratis corneal tissue, please fill out the form below.

Surgeon:
Location in the service area? Yes No
Date of Surgery:
Place of Surgery:
Email:
Phone:

Patient:

Residence in the service area? Yes No

Street:

City: State Zip:

Country:

Surgeon's fee waived:
yes no

Surgery Center's fee waived:
yes no

Name of individual at surgery center agreeing to fee reduction: