Wave Clinical Support - Ortho-K Lenses

Wave Clinical Support Request Form - Ortho-K Lenses
Clinical support is only available for Ortho-K lenses within the FDA approved treatment range (up to -5.00D of Myopia and -1.50D of Astigmatism).

Please use this form for Post-dispense Ortho-K cases. 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
WAVE Account Number:*
Wave acct. # (ex: AA00189)
Patient Name:*

First NameLast Name
Patient's Age?
Order ID: OD
Order ID: OS
How many days is this patient using these lenses?
What solutions have been used?
Is patient using Atropine?

YesNoUnsure
Reason for CS Submission

res myopiares myopia and / or astigmatismdecentered TZ downdecentered TZ updecentered TZ laterallydiscomfortglareres hyperopia
INITIAL EXAM

Presenting Eyeglasses

	SPH	CYL	AXIS	ADD	Far VA	Near VA
OD
OS

Subjective Refraction*

	SPH	CYL	AXIS	ADD	Far VA
OD
OS

OR (Over Refraction) / VA (This is CLs On)

	SPH	CYL	AXIS	Far VA
OD
OS

Fit Evaluation (NaFl)

	Bullseye	Centration	Movement	Inner Alignment Zone Fit	Outer Alignment Zone Fit
OD
OS

VA (CLs OFF)*

	Far VA (CLs OFF)
OD
OS

SR (Post Treatment Spectacle Refraction) / VA*

	SPH	CYL	AXIS	Far VA
OD
OS

Tangential Difference Map Evaluation (Topographer)*

	Treatment Zone Shape	Treatment Zone Quality	Treatment Zone Size: Pupil Size	Treatment Zone Centration
OD
OS

Other Comments
Click to upload Files*

Upload a File
Max Total Upload Size: 500MB Cancelof
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: mdb, U12, mxf, mdb, U12, mxf, zwt, jpg, mp4, png, Pdf, GIF, TIFF, PSD, MOV, AVI, FLV, MKV, WMV, MPEG-4

Instruction Videos: how to export files from your topographer?
- Medmont: https://www.youtube.com/watch?v=exko8rFKJ-g
- OCULUS Pentacam/Keratograph: https://www.youtube.com/watch?v=ZBjqnREZhkU
- Scout: https://www.youtube.com/watch?v=ztiAQZswq_g
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.
Do you give consent for WAVE Clinical Support to anonymously use any patient submitted data (topographies, images, etc.) in presentations and training materials?

YesNo
Should be Empty:

Wave Clinical Support Request Form - Ortho-K Lenses