Health Testing Necessary for Proper Patient Care In order to provide PREVENTATIVE eye health evaluations and PRESERVE your sight with EARLY DETECTION of systemic (body) disease and ocular (eye) disease, the following tests must be performed on all patients annually. Your vision insurance does not cover the cost of these vital tests, yet they are necessary for proper eye health examinations. These health tests are being offered to you at a reduced fee as follows: RETINAL PHOTOGRAPHY Taking YEARLY colored photographs of the inside or back of the eye is much like a dentist x-raying your mouth annually. The photos of the retina will document the internal health of the eyes and allow for accurate yearly comparisons. This allows your doctor to detect early eye health changes and can dictate treatment if necessary. iWELLNESS Like an MRI of the eye, the iWellness Exam reveals ocular anatomy and signs of disease in exquisite detail. This breakthrough technology allows your doctor to examine, with unprecedented clarity, structure that is INVISIBLE using traditional methods. This unique technology can help detect potentially vision threatening diseases such as Glaucoma, Macular Degeneration, and others in their earliest stages, thus improving outcomes. The fees for these necessary services are due TODAY and are indicated below* YES, I choose to have both RETINAL PHOTOGRAPHY AND iWELLNESS performed at a fee of $60 YES, I choose to have RETINAL PHOTOGRAPHY ONLY performed at a fee of $45 NO, I choose to decline these health tests. I understand the risk involved with declining. Patient Name First Last SignatureDate MM slash DD slash YYYY
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