Corneal Preference Request

Physician Name

Practice Name

Death to Surgery (how many days)

Death to Preservation (how many hours)

Age Range of Donor

Cell Count Range

DSAEK thickness preference DSAEK thickness preference Less than 60 (specify minimum below) 61 - 90 microns 91 - 120 microns 120 - 160 microns

Other: Specify min. and/or range

Graft Diameter: Standard diameter, 10mm

DSAEK Orientation Markings DSAEK Orientation Markings Centration Dot Exit Mark Peripheral Gutter Markings (4 quadrant markings placed) F Stamp S Stamp

Other: Please specify

DMEK Orientation Markings DMEK Orientation Markings F Stamp S Stamp

Pre-Punched Pre-Punched Yes No

Preferred Pre-Punched Graft Diameter (7mm - 8.5mm)?

Do you want your tissue pre-loaded? Do you want your tissue pre-loaded? Yes No

Pre-Loaded DMEK Diameter Pre-Loaded DMEK Diameter 7mm 7.25mm 7.5mm 7.75mm 8mm 8.5mm

Other: Please specify