Through the Eyes of a Recipient
What Do We Do?
How Can You Help?
$ Contribute $
ILEB RECIPIENT STORY SUBMISSION PAGE
= Required Field
Address 2: (if needed)
District of Columbia
Federated States of Micronesia
Northern Mariana Islands
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Your Relationship to recipient:
Date of transplant:
Share your Story
Suggestions for sharing your story:
What was life like for you and your family before and after the transplant?
How has the transplant changed your vision? (Mention things you can do now that you could not before the transplant)
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RadEditor's bottom area: Design, Html and Preview modes, Statistics module and resize handle.
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RadEditor's Modules - special tools used to provide extra information such as Tag Inspector, Real Time HTML Viewer, Tag Properties and other.
Upload Photo (optional but strongly encouraged):
Consent For Use:
I hereby give my consent for Iowa Lions Eye Bank to share my story in publications, on its website, via social and news media and at public events. I have been informed that my story may be edited prior to publication. I hereby give my consent to participate in a promotional story, program, advertisement, and/or image (photograph and/or videotape) made for or about Iowa Lions Eye Bank and/or University of Iowa Health Care in which I will be interviewed and quoted by name. I have been told that this story, program, advertisement, and/or image (photograph or videotape) may appear in the public media, including print, internet, and/or broadcast media for a period of up to six (6) years. I have been told that story, program, advertisement, and/or image (photograph and/or videotape) may be used by Iowa Lions Eye Bank and/or UI Health Care more than once for promotional purposes. I have been told that my health care and the payment of my health care will not be affected if I do not sign this form. I have been informed that once information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and that I may revoke this authorization at any time by providing notice in writing to the following address: UI Health Care Marketing and Communications, University of Iowa Health Care, 200 Hawkins Drive, W319 GH, Iowa City, IA 52242-1009. The revocation will not affect any actions taken before the receipt of this written notification. Questions? 319-356-1009 Iowa Lions Eye Bank and the University of Iowa Health Care will not receive, directly or indirectly, financial compensation from a third party for the use and/or disclosure of the health information described above.
I have read the above consent for use, understand it completely, and agree to it in full:
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