Tissue

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Tissue Request Form

Please email the completed form to distribution@lebnortheast.org at least ONE (1) week prior to surgery.

IF THIS IS AN EMERGENCY, PLEASE CALL 518-489-7606.

* = Required
Surgeon Information
Patient Information (Optional)
Tissue Information
WE WILL CONTACT YOU TO CONFIRM GRAFT PREPARATION DETAILS WITHIN 24 HRS.
Shipping Instructions
THANK YOU FOR YOUR REQUEST