Allograft Bone | human tissue bank | Tissue Transplant


It is the responsibility of the health care professional completing this form to submit the information to the distributing facility. If any questions, problems, or adverse reactions occur, please notify Alamo Tissue Services at 210.738.2663 or 800.226.9091 and we will be happy to assist you.

Tissue is for single use only.

Please complete the patient information below:

First Name: *
    		Last Name: *

MI:
    		Patient ID Number: *

Date of Birth (mm/dd/yyyy): *
    		Gender: *

Hospital or Surgical Center: *
    		City: *

State: *
    		Physician: *

Diagnosis: *
    		Date of Surgery (mm/dd/yyyy): *

Surgical Procedure:









Data Provided By: *
    		Email: *

Comments:

Tissue ID #1: *
    		Tissue Description #1: *

Tissue ID #2:
    		Tissue Description #2:

Tissue ID #3:
    		Tissue Description #3:

Tissue ID #4:
    		Tissue Description #4:

Additional Comments:
    		Overall satisfaction rate of the graft:

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  5844 Rocky Point Drive    |    San Antonio, TX 78249    |    P 210-738-2663    |    800-226-9091    |    F 210-732-4263    |    info@alamotissueservice.com