Cornea Donor On-boarding Form

Personal Details

 


Medical History

1. Human Immunodeficiency Viruses (HIV)

2. Hepatitis B and C

3. Creutzfeldt-Jakob disease (CJD) or Varient Creutzfeldt-Jakob disease (vCJD)

4. Syphilis

5. Tuberculosis (TB)

6. Ocular or Systemic Herpes simplex virus (HSV) or Varicella Zoster Virus (VZV) Infections


Next of Kin

 


Confirmation