Research Tissue Request Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Research Project: Please provide an overview of the research project
What type of tissue is needed
Whole Eye
Cornea
Posterior Pole
Conjunctiva
Lens
Other
Other
How many tissue do you need?
Timeline
Is there an age requirement?
What is the acceptable Death to Recovery/Preservation interval? (Standard is
What is the required storage media? If different than moist chamber or Optisol GS, are you able to provide it?)
Is there any special preparation needed for the tissue (i.e slit for preservation media, frozen, precut)?
Please specify any serologic testing that is mandatory for the project.
Please list any special donor criteria for this project
What is the ideal death to receipt interval?
Submit
Should be Empty: