iWellness Screening Form Consent for iWellness Screening Tests Please be sure to check the consent box before submitting the form.Consent(Required) As part of our commitment to provide you with the most comprehensive eye care, we offer advanced high-definition digital imaging which allows Dr. Dada and associates to gain a better understanding of any dangerous conditions that may be developing in your eyes. Many eye problems can develop without warning and progress without symptoms. In the early stages, you may not even notice a change in your vision, but sight threatening conditions such as retinal detachments and diseases such as macular degeneration, glaucoma, diabetic retinopathy can be detected with a thorough evaluation of the retina, the iWellness Exam. The iWellness Exam is a fast, simple procedure that can help your doctor detect common eye disease. Dr. Dada and associates strongly encourages all patients to undergo these valuable tests as part of your annual eye exam, and particularly for any individuals with any of the following: Spots, floaters, or flashes Hypertension Diabetes Eye pain / Headaches History of head or eye trauma Family history of glaucoma Family history of AMD (macular degeneration) Strong eyeglass prescription Anemia Co-pay for iWellness Exam: HD Retinal Photos & iWellness Scan $65Do you wish to participate in the iWellness Exam?(Required) I DO wish to participate in digital screening to assist in early detection of eye disease, and understand I am responsible for charges not covered by my insurance. I REFUSE to participate in the advanced imaging procedures and release Dr. Dada from any liability for future vision loss related to my unwillingness to allow him to obtain information. Name(Required) First Last Signature(Required)Date MM slash DD slash YYYY CAPTCHA Δ
