| agree to allow video or photographs to be taken of me/my child for reference purposes as a means of evaluating performance and documenting progress. The Performance Vision Training Center Team may use the images for the following:(Required)

● Evaluation Purposes
● Professional presentations and or publications for Parents, Therapists, Doctors,
and/or Educators. These presentations occur at local, state, national and
international conferences.
● Brochures or other Marketing Resources.
● Motivational Awards (Including graduation/completion of program Award).
● The Vision Development Team's Website, Facebook page, and Newsletter
● Binovi App Training videos that can be viewed by other patients at our practice

PRIMITIVE REFLEX Questionaire

THIS APPOINTMENT IS 2 HOURS LONG.

Please bring or wear shorts and a short-sleeved shirt.

Pregnancy/Birth History

Ear, Nose and Throat

Vision

Auditory

PVTC Video and Photo Release Agreement

Vision Source Specialists