Click to download and customize
or copy and paste text below.
RightEye Dynamic Vision Test
The RightEye Dynamic Vision test is a highly sophisticated, eye-movement technology system used to objectively measure, analyze and evaluate how well your eyes move or work together. This test allows us to pinpoint functional vision issues that often go undetected and if left untreated can negatively impact your quality of life.
We recommend all our patients receive a RightEye test annually. It is especially important if you have experienced any of the following signs of a possible dynamic vision problem:
- Difficulty concentrating
- Rereading or skipping lines of print
- Short attention span
- Poor reading comprehension
- Poor coordination or balance
- Slow completion of work
- Previous brain trauma (concussions, strokes)
- Loss of interest in reading
- Headaches
- Nausea or dizziness
| $49 | ___ Yes, I do want the RightEye Dynamic Vision test |
| ___ No, I do not want the RightEye Dynamic Vision test |
| Alternate text for identifying symptomatic patients/billing insurance | |
| ___ Yes, I have one or more of the above symptoms | |
| ___ No, I don’t have any of the above symptoms |
Patient’s Signature: _____________________________Date: __________
Printed Name: ________________________________________________