Wave Ortho-K Concierge Dispensing / Follow-up Form

WAVE Ortho-K Concierge Dispensing / Follow-up Form

Minimum number of Nights: 7
Concierge service is only available for Ortho-K lenses within the VST approved treatment range (up to -5.00D of Myopia and -1.50D of Astigmatism).
Doctor Name:*

First NameLast Name
WAVE Account Number:*
Wave acct. # (ex: AA00189)
Email Address:*
Email
Phone Number*

Area CodePhone Number
Patient Name:*

First NameLast Name
Patient's Age?
Wave Original Order id number, OD
Wave Original Order id number, OS
How Many Days is this Patient using these Lenses?*
How Long Total?*
What Solutions Have Been Used?*
Is patient using Atropine?

YesNoUnsure
Corneal Diameter, OD
Corneal Diameter, OS
With Contact Lenses On

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

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

	SPH	CYL	AXIS	Far VA	Near VA
OD
OS

Fit Evaluation (Rotation)

	Lens rotated	How many degrees?
OD
OS

Click to upload Files

Upload a File
Max Total Upload Size: 500MB Cancelof
Please upload Slit Lamp Images and Videos! The Fluorescein patterns provide additional information about the lens design.

These are the file types / extensions that are allowed: jpg, mp4, U12, PNG, .WEBM, .MPG, .MP2, .MPEG, .MPE, .MPV, .OGG, .MP4, .M4P, .M4V, .AVI, .WMV, .MOV, .QT, .FLV, .SWF, .MXF, .ZWT, .XML
Other Comments
Without Contact Lenses On

VA (CLs OFF)*

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

SR (Post Treatment Spectacle Refraction) / VA*

	SPH	CYL	AXIS	Far VA	Near VA
OD
OS

Click to upload Files*

Upload a File
Max Total Upload Size: 500MB Cancelof
Please upload Post Treatment Topography Files! (Please do not upload topographies as image files.)

Instruction Videos: how to export files from your topographer?
These are the file types / extensions that are allowed: mdb, mfx, jpg, mp4, U12, PNG, ZWT, XML
Other Comments
Should be Empty:

WAVE Ortho-K Concierge Dispensing / Follow-up Form