Vision Therapy Online Test

1

Current Grade Level* This field is required.Current grade level or the grade they will be entering in the next semester.

Kindergarten

First Grade (1st)

Second Grade (2nd)

Third Grade (3rd)

Fourth Grade (4th)

Fifth Grade (5th)

Sixth Grade (6th)

Seventh Grade (7th)

Eighth Grade (8th)

Ninth Grade (9th)

Tenth Grade (10th)

Eleventh Grade (11th)

Twelfth Grade (12th)

College

Everyone outside of college

2

Is there any evidence from the school or a psychological test that some visual difficulties may be present?If so, what? Please explanation.

4

Name* This field is required.Patient's Name

First Name

Last Name

5

Phone Number* This field is required.By submitting, you agree to receiving a call regarding your results.

ex. (123)456-7890

6

Email* This field is required.By submitting you agree to receiving an email regarding your submission and any future vision therapy information, you can opt out using the link in the email. We do NOT sell email addresses to a third party.

example@example.com

7

We'd like to contact you regarding your results. Should we call or email?* This field is required.

CallEmail

8

Please verify that you are human* This field is required.

9

Here's your score!We recommend, with a score of one (1) or higher, that you contact us and schedule an eye exam. If you have already had an eye exam this year, schedule an office visit to discuss your concerns with our Developmental Optometrist.