ISON Agreement The I See Over Night Program includes the flilowing: Initial ISON Evaluation, fitting, and consultation ALL lens changes made by the doctor for the first 12 months Two pairs of retainer lenses; 2nd pair will be dispensed after treatment has been stabilized All flilow-up care for the first two years; including 1st yearly evaluation after the initial enrlilment All topographical and diagnostic testing After the first two years (2 years), the I See Over Night Program does not include: Annual Comprehensive eye health exam I See Over Night Maintenance Program Cost for yearly exams, after the two year (2 year) Program has ended, is $365 every 12 months. If more than 12 months has passed, evaluation will be $377. Guarantee: If Circumstances prevent you from continuing your treatment during the first three months (3 Months) of care, EyeSymmetry will gladly refund all fees paid less $700. Fees: Option: Interest-Free Financing LEVEL 1$2250 LEVEL 2$2750 LEVEL 3$3300 LEVEL 4$3600 LEVEL 5$4400 * If payment is made in full at the time of the purchase, without any special financing, there will be a special discount of $229.00 (Two hundred twenty nine dollars) In the Event that a retainer lens has to be replaced, there is a replacement fee. Lens Replacement fee (per lens) Single Vision Lens$265 Multi-focal Lens$365 *Prices are subject to change without notice* (Required) I have read and understand the above, and I am in agreement with the contents.Patient Name:(Required) First Last Patient/Parent or Guardian Signature:(Required)Date(Required) MM slash DD slash YYYY
