In order to help others who are trying to decide how soon to start Vision Therapy, we would appreciate it if you could write a few words of encouragement. It would be helpful if you could share what life was like before starting Vision Therapy and how it is now. Please share what you have gained by doing our program.

Before Vision Therapy

was having problems with

Please review and answer the questions below.

Would you be willing to talk with others considering vision therapy?

Yes
No

Would you be willing for your/your child’s story to be included

on our website or facebook?
in a printed pamphlet?

would it be okay to use your/your child’s first name or would you prefer we use a different name?

Would you allow us to put a graduation photo of you/your child on our website or facebook?

Yes

Signed

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Date

Name

First Last

Relationship to Patient

Share Your Success

Dolman Eyecare Centre

KW NeuroVision