Visual Skills Exam Form
(Part 2)

Please fill out Part 1 and Part 2 to complete your paperwork. If you have any questions please call us at 520-886-8800.

VSE Form

Policies & Consent

Photo / Video Permission

Please select your permission level:

Permission for office, education, and marketing use

Permission for in-office use only

No permission granted

Payment Responsibility

I understand that Arizona Vision Therapy Center is not contracted with insurance companies. I am financially responsible for all charges at or before the time of service. Invoices will be provided so I may submit claims to my insurance company. I understand past-due balances accrue 10% monthly compound interest.

Medicare Status

Are you a Medicare Part B beneficiary?

Yes

HIPAA Acknowledgment

I acknowledge that I have received or been offered the Notice of Privacy Practices for Arizona Vision Therapy Center.

Cancellation Policy

I understand that appointments require 24-hour notice for cancellation (48 hours for Visual Skills Exams). Missed or late-cancelled appointments will be charged $105.

Ocular Health Understanding

I understand that visits at Arizona Vision Therapy Center focus on how the eyes and brain work together. These visits do not replace routine eye health exams with my primary eye doctor or ophthalmologist.

Arizona Vision Therapy Center

Visual Skills Exam Form (Part 2)

VSE Form

Policies & Consent

Arizona Vision
Therapy Center

Visual Skills Exam Form
(Part 2)