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BioTissueProvider Application

Interested in Becoming a BioTissue Provider?

BioTissue’s Find-A-Surgeon directory aims to connect patients with healthcare providers who can deliver better patient outcomes through the use of amniotic membrane and umbilical cord products in their treatment protocol. To be included in the list, you must have experience using amniotic membrane or umbilical cords allograft products.

Please fill out the form below as accurately as possible. All fields are required to register in the directory. Only your Full Name, Specialty Areas and Practice Contact Information will be visible to patients. Once your information is verified, you will receive a confirmation notification in the email you provided below.

Provider Application

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Ex. MD, DPM, FACFAS, DO
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Enter the phone number for patients to contact your practice
Please include suite or room number
Please include suite or room number
Specialty Areas(Required)
Check all that apply. *
Consent Data(Required)
Consent Terms(Required)
This field is for validation purposes and should be left unchanged.
Distinguishing FeatureATD Dry EyeMechanical Dry Eye
Diurnal variation
Worse gaze		Worse in PMSame throughout the day
Up gazeDown gaze
Effect of vigorous blinkingSymptoms improvedSymptoms worsened
Recurrent subconjunctival hemorrhageInfrequentFrequent
Flourescein staining patternLow tear meniscus without interruptionTear meniscus interruption or obliteration
Tear clearanceNormal/DelayedFrequently delayed
Rose bengal stainingExposure zoneNon-exposure zone
Effect of punctal occlusionSymptoms improvedSymptoms worsened
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