Tissue Request Form

Purpose: PKP      LKP      Anterior Lamellar Amniotic Membrane      PLEK / EK       Tube Reinforcement Graft

Diagnosis: Comments On Tissue / Specifications :

Today's Date: 07/05/08

Date Needed:

Surgery Date: Time:

If this is a Monday surgery, please provide a Sunday contact name & telephone number, otherwise, please provide weekday contact information.

Contact Name:

Telephone Number:

Recipient Information:

Is this a scheduled request due to a previously cancelled surgery? Yes No

If YES, please enter:

Original tissue request number:

Original surgery date:

Additional Patient Information:

First Name:

Last Name:

Street:

City: State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:

Country:

Date of Birth:

Age:

Gender: M F

SSN:

Medical Record #:

Residence in the service area? Yes No

Hospital/Clinic Information:

Requirement Note:

Surgeon:

Contact Name:

Contact Phone:

Surgery Site:

PO#:

Shipping Information:

Facility:

Street: City:

State: Zip:

Tracking System Disclosure and Agreement:

LEBT-BCM is required to have an effective system in place which enables effective tracking of all tissue-based products from the donor to the recipient (or final disposition). Each product container is sealed and labeled with a unique identifying number that allows for efficient tracking and maintains patient confidentiality between recipient and donor. As part of the tracking system, LEBT-BCM is required to obtain specified, traceable recipient information prior to tissue distribution or upon final disposition. Per FDA regulations (21CFR Part 1271.290) LEBT-BCM is also required to inform the consignee that a tracking system has been established for all tissue-based products provided and that you (the consignee) will have certain responsibilities under this system. As a condition of this request for tissue, you must indicate below that you agree to: · Provide LEBT-BCM with specified recipient information prior to surgery or immediately following the surgical use of tissue; · Notify LEBT-BCM upon any occurrence of the tissue being discarded or used for non-surgical purposes; · Following surgery, you (or your associate) must complete (and verify) the information on the Tissue Recipient Information Form provided with the paperwork accompanying the tissue shipment and return it promptly to LEBT-BCM; and · Place and maintain documentation in the recipient’s medical records, and other pertinent records, indicating that the tissue product was implanted/transplanted or otherwise documented that the tissue was disposed in an appropriate manner.

Acknowledgement: You (and your associates) understand these responsibilities and fully agree to participate in the tracking system. I agree: