Vision Therapy Cosnent Form

Thank you for your interest in the Vision Therapy Program.

This program is NOT to cure your condition, but to offer you stronger, improved, more comfortable vision that spectacles alone cannot provide. Vision therapy may be useful for amblyopia, strabismus, phoria, visual perception, visual processing, visual tracking and others. However, since each individual case is different, no guarantees can be made.

In order for this process to be successful, all instructions, homework, and follow up appointments must be followed.

Type a question

	Patient Initials
Each patient will be provided with a home vision therapy kit for homework exercises and maintenance. The fee for each kit is $50.
After the initial evaluation, a vision therapy program will be customized to meet the patient’s needs. Each program will include regular in office training in 40 minute intervals. On average, a minimum of 4 sessions is recommended. However, the amount of sessions will depend on the patient’s progress which will be periodically checked.
After the initial evaluation, a vision therapy program will be customized to meet the patient’s needs. Each program will include regular in office training in 40 minute intervals. On average, a minimum of 4 sessions is recommended. However, the amount of sessions will depend on the patient’s progress which will be periodically checked.
After the initial evaluation, a vision therapy program will be customized to meet the patient’s needs. Each program will include regular in office training in 40 minute intervals. On average, a minimum of 4 sessions is recommended. However, the amount of sessions will depend on the patient’s progress which will be periodically checked.
Additional materials or equipment may be loaned out to patients. Loss or damage of these items will incur an additional fee for replacement.
Most insurances do not cover vision therapy/orthoptics. Payments must be made after each session in order to continue the program. Each 40 minute one-on-one session’s fee is $150.
Cancellations or reschedules must be made 24 hrs in advance. A cancellation fee of $50 will be applied if not made within the specified time frame.

Signature of Parent or Legal Representative*

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Date*

If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.

Name of Legal Representative

First NameLast Name

Relationship to Patient

Vision Therapy Consent Form