iWellness Form Please enable JavaScript in your browser to complete this form. Your eyesight is priceless and we are here to protect it! Vision threatening diseases such as glaucoma, macular degeneration and diabetic retinopathy often have no outward signs or symptoms in the early stages, so our practice has begun using state-of-the-art technology to assess the health of your eyes. The iWellness Exam is a quick, non-invasive scan that allows our doctor to see beneath the surface of the retina. This unique technology can help our doctors detect vision threatening and systemic diseases in their very early stages, when they are most treatable. As part of your pre-exam testing, our technician will perform the iWellness Exam which our doctor will review with you during your examination today. The $39.00 charge IS NOT COVERED BY YOUR VISION OR MEDICAL INSURANCE, SO THIS WILL BE ADDED TO THE COST OF YOUR VISIT TODAY. Any questions you have about this iWellness Exam and the results of the results of the test can be discussed with the doctor during your examination. Please note this is just a screening. If the doctor feels that it should be done for medical reasons we will do a more detailed version and at that time should be covered under your medical insurance, depending on your particular policy.Please initial only one:YES, I would like the iWellness ExamNO, I do not want the iWellness ExamPrint Name *FirstLastSignatureClear SignatureDateWebsiteSubmit