Halo Request Form | Saving Sight

Halo Order Request Form

Contact our Client Services team to place your order for Halo sterile tissues

Halo Request Form

Surgeon Information
Surgeon Name*
First Last
Phone*
Email*
Surgery Information
Surgery Location*
City*
Surgery Date
MM slash DD slash YYYY
Surgery Time

: Hours

Minutes

AM/PM
Patient Information
Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
Diagnosis
Identification (MRN, SSN, etc)
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Halo Tissues

TISSUE	SHAPE	WHOLE/HALF	THICKNESS	SIZE	PRODUCT
Cornea		Half	Half	8.5mm	HCO-HH1
Cornea		Full	Half	9.5mm	HCO-FH2
Cornea		Full	Full	9.5mm	HCO-FF3
Sclera		N/A	N/A	10mm x 10mm	HSL-NA2
Sclera		N/A	N/A	10mm x 10mm	HPE-NA1

Please enter your desired quantity of each product displayed in the table above according to its corresponding product number.
HCO-HH1 Cornea Quantity
HCO-FH2 Cornea Quantity
HCO-FF3 Cornea Quantity
HSL-NA2 Sclera Quantity
HPE-NA1 Pericardium Quantity