WAVE ScleraLens Concierge Dispensing / Follow-up Form

Over Refraction / VA and Lens Rotation

	SPH	CYL	AXIS	Far VA	Near VA	Lens Rotated	How many degrees?
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

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Please upload Slit Lamp Images and Videos!
- OCTs images: center and at least periphal scans (LC, Aligment zone)
- And/or photo with fluo for central and periphal fit, evaluation (AC, LC and edge alignment)
These are the file types / extensions that are allowed: jpg, jpeg, mp4, U12, PNG, .WEBM, .MPG, .MP2, .MPEG, .MPE, .MPV, .OGG, .MP4, .M4P, .M4V, .AVI, .WMV, .MOV, .QT, .FLV, .SWF, .MXF, .MSR, .ZWT
Patient's subjective impression regarding comfort*
Other Comments
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