The Vision Training Program will commence on   Type a label, 20   Type a label, and end on   Type a label, 20   Type a label, and includes:

• » 24 weeks of in-office vision training sessions, scheduled once per week
• » Training sessions are 45 minutes in length and begin at the top of the hour
• » 2 progress evaluations by the provider around 10 weeks and around 22 weeks at no additional charge

The fee for the Vision Training Program is: $3,792.00
Please select the outside funding program to be billed for all therapy sessions:
PASSS Funding   Other   Type other   

The required home vision therapy equipment may be purchased or rented.
Rental Kit - $150   Purchase New Kit: $290   Continuing therapy, kit already rented: $0      

Each patient’s individualized Training Program has been prepared by a doctor. Training will be conducted by a trained Optometric Vision Therapist. As a patient progresses through the program, the amount and type of training required may change. This is due to improvements being made more, or less, quickly than anticipated. We are here to provide the best possible care for our patients and if you have any questions or concerns, please contact the office at any time.

Please Initial each item:
Initial Some funding programs only pay for therapy sessions and do not pay for examinations or doctor appointments. I understand that it is my responsibility to pay for any examination fees not covered by the funding program. 
InitialIt is the patient or parent/guardian’s responsibility to make sure the correct funds are allocated properly for payment.
Initial  If the funds are not correctly allocated, it is the patient or parent/guardian’s responsibility to pay any amount exceeding the funds available.