Tissue Tracker – Ventris Medical®

Tissue Traceability Record
The Joint Commission and the US FDA requires tissue tracing systems in all facilities using allograft tissue for transplantation. In order to comply with these requirements, please complete and submit this form. If any tissue is discarded, please notate reason in the comments section.
Allograft Information
Tissue or ID Number*
Donor Number*
Patient Information
Name*

First NameLast Name
Patient Number*
Gender*
DOB*

MonthDayYear
Date of Birth
Upload Patient Label*

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Surgeon/Facility Information
Facility Name*
Surgeon Name*
Upload Surgeon/Facility Label

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Procedure Information
Graft Disposition*

UsedDiscarded
Date of Surgery*

MonthDayYear
Date
Procedure Performed*
Upload Product Label*

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Comments
Email*
We will email a copy of this form to the email provided.
Should be Empty:

Tissue Traceability Record