Wave Clinical Support - Scleral Lenses

Please use this form for Post-dispense Wave Scleral Lenses. Clinical Support may not be used for consultation on new Wave Contact Lens orders that have not been dispensed and evaluated.

If you can not finish the Clinical Support form and want to come back to complete at a later time, click on the SAVE buttom at bottom of form. You will receive an email with link to form to complete at a later time.

Doctor Name:*

First NameLast Name

Email Address:*

Email

Account Number:*

Wave acct. # (ex: AA00189)

Patient Name:*

First NameLast Name

Patient's Age?

Order ID: OD

Order ID: OS

Using any Lens care System?

INITIAL EXAM

Presenting Eyeglasses

	SPH	CYL	AXIS	ADD	Far VA	Near VA
OD
OS

Subjective Refraction

	SPH	CYL	AXIS	ADD	Far VA	Near VA
OD
OS

Dominant Eye

Select which eye is dominant

Target

Select Target

Presenting Contact Lenses

	SPH	CYL	AXIS	ADD	Far VA	Near VA
OD
OS

Diagnostic Trial Lenses

	Base Curve (mm)	Base Curve (D)	Diameter	Power
OD
OS

Trial Lens Over Refraction (OR)

	SPH	CYL	AXIS	ADD	Far VA	Near VA
OD
OS

HVID:

Pupil Size:

Other Comments

Click to upload Files*

Upload a File

Max Total Upload Size: 500MB

Please upload Topography Files, Slit Lamp Images and Videos!

In order to better help with your case, please export the baseline and post dispense topography files and upload them here.

Please do not upload topographies as image files.

These are the file types / extensions that are allowed to be uploaded: mdb, U12, mxf, zwt, jpg, mp4, png, GIF, TIFF, TIF, bmp, pdf, PSD, MOV, AVI, FLV, MKV, WMV, MPEG-4

Instruction Videos: how to export files from your topographer?

Medmont: Medmont
OCULUS Pentacam/Keratograph: OCULUS
Scout: Keratron Scout

Fit Evaluation (OCT and / or Slit Lamp)

	AC (μm)	Edge Alignment @3:00	Edge Alignment @6:00	Edge Alignment @9:00	Edge Alignment @12:00
OD
OS

DISPENSING VISIT

VA

	Far VA (CLs ON)	Near VA (CLs ON)
OD
OS

OR (Over Refraction) / VA

	SPH	CYL	AXIS	Far VA	Near VA
OD
OS

Fit Evaluation (OCT and / or Slit Lamp White Light & Fluorscein )

	Time of wear-hours	AC (μm)	Limbal Clearance (μm)	Edge Alignment @3:00	Edge Alignment @6:00	Edge Alignment @9:00	Edge Alignment @12:00
OD
OS

Fit Evaluation (Rotation)

	Lens rotated	How many degrees?
OD
OS

Other Comments

FOLLOW-UP VISIT

VA

	Far VA (CLs ON)	Near VA (CLs ON)
OD
OS

OR (Over Refraction) / VA

	SPH	CYL	AXIS	Far VA	Near VA
OD
OS

Fit Evaluation (OCT and / or Slit Lamp)

	AC (μm)	Limbal Clearance (μm)	Edge Alignment @3:00	Edge Alignment @6:00	Edge Alignment @9:00	Edge Alignment @12:00
OD
OS

Fit Evaluation (Rotation)

	Lens rotated	How many degrees?	Hours of Wear at Evaluation
OD
OS

Other Comments

Do you give consent for WAVE Clinical Support to anonymously use any patient submitted data (topographies, images, etc.) in presentations and training materials?

YesNo

Please be sure to upload the Topography Files and fill out the form as much as possible. Missing information will cause delays in providing you with clinical support.

A copy of this form is emailed to you as a "receipt". You will receive an email or call from Clinical Support shortly.

Wave Clinical Support Request Form - Scleral Lenses