Healthcare Corneal Processing Form

HEALTHCARE CORNEAL PROCESSING FORM

Patient Information

Patient Name:   Date of Birth:

Donor / Specimen Identification

Specimen ID:   Laterality: Right Left Bilateral

Clinical Indication & Procedure

Medical & Ocular History

Processing Instructions & Laboratory Tests

Please select required processing, testing, and disposition options. If multiple boxes are selected, process in listed priority unless directed otherwise.

Microbiology Culture (corneal rim):   Histopathology:   Endothelial Cell Count:

Serology (donor screening / recipient testing):   Pachymetry:

Microbiology & Serology Orders

HIV (Ag/Ab):   Hepatitis B (HBsAg):   Hepatitis C (HCV):

Syphilis (RPR/TP):   Other:

Storage, Use & Disposition Authorization

I authorize handling of the corneal tissue as indicated below (select all that apply). I understand that once tissue is released for transplantation it may not be recovered. I understand there may be tests required by the processing facility that will be performed for safety and quality assurance.

Store for transplantation:   Use for research/education (de-identified unless otherwise indicated):   Use for quality assurance:

Dispose if not suitable for intended use:   Return unused tissue to provider:

HIPAA Authorization & Privacy Acknowledgment

I authorize release of my protected health information, including the corneal tissue processing results, microbiology, serology, and related clinical information, to the processing facility and affiliated laboratories for the purposes of tissue processing, testing, quality assurance, and required reporting. I understand that identifiable information is necessary for matching and safety testing.

I understand that I may revoke this authorization in writing at any time prior to tissue release for transplantation; however, revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation. Revocation may not be effective if tissue has already been used or released.

Consent & Certification

By signing below I certify that I have read and understand the information on this form, that the nature and purpose of corneal tissue removal and processing, including testing and potential uses (transplantation, research, education, quality assurance, disposal), have been explained to me, and that I have had the opportunity to ask questions. I understand risks include but are not limited to loss of tissue for intended use, potential disclosure of health information necessary for testing and matching, and that certain tests may be required for safety and regulatory compliance.

I acknowledge that alternatives and questions were addressed and that signing is voluntary. I authorize the processing facility to perform the tests and handling indicated above and to release results to the ordering provider and treating team for clinical care and safety monitoring.

Relationship to Patient (if signing as representative):

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