Home Therapy System (HTS) Consent Form

Thank you for your interest in our Home Therapy System (HTS) Program.

 This therapy program is aimed to train eye muscles with a computer based software and other tools, all included in a convenient kit.

 In order to be successful, it is necessary to commit 20 minutes a day, 5 days a week to this program; or as recommended by the doctor. If you are unable to set aside this time, this is not the therapy option for you.

 The goal is to improve the quality of life by re-training the eye muscles and/or strengthen the weak muscles. If you wear glasses or contact lenses, you will still need them during and after the program.

 

Fees: $399

The Computer Vision Therapy kit includes:

• Computerized Binocular Screening Program (CD-ROM) with tech support
• Red/Blue Computer Glasses
• Set of Flipper Lenses

I have read and understand the above conditions and I will comply with the accordance and contents.

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