RightEye Sensorimotor Order Form

Thank you for your interest in RightEye Sensorimotor!

We're excited to get you started.

IMPORTANT NOTES:

RightEye Sensorimotor is designed to work optimally on two RightEye VisionTracker2 devices (our all-in-one portable unit shown below) as outlined in our Implementation Guide.

RightEye Sensorimotor has only been validated on the RightEye VisionTracker2 and will not be available on earlier RightEye hardware models, e.g. RightEye VisionTracker with standalone eye-tracker and Alienware or Zotac brand computer.

If you don't currently have our VisionTracker2 device, or only have one VisionTracker2, you can order additional devices for purchase below.

VisionTracker2

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* Please provide your contact information.

Name

Practice

Email Address

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* Please confirm you wish to activate the RightEye Sensorimotor software module (included in your current subscription package at no extra charge).

Yes, please activate my Sensorimotor software module

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* How many VisionTracker2 units would you like to purchase at this time? (Cost is $3,997 plus shipping each. RightEye will send you a quote for your approval. Once your signed quote and payment are received, your order will be fulfilled.)

None

Other (select to manually enter quantity)

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* Optional At-Home Remedy Available (Restrictions Apply)
How many HTS2 Home Vision Therapy Patient Kits would you like to purchase? (One pack of seven kits is $389.70. RightEye will send you a quote for your approval. Once your signed quote and payment are received, your order will be fulfilled.)

Restrictions:
1) RightEye is not authorized to sell HTS2 kits to current HTS customers. If you're a current HTS customer, please contact HTS directly.
2) HTS allows RightEye to purchase licenses for medical doctors only; HTS2 kits are not available for purchase by non-medical doctors.

None at this time

7 Patient Kits

14 Patient Kits

21 Patient Kits

28 Patient Kits

35 Patient Kits

Other (select to manually enter number of kits (in increments of seven)

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* Please confirm you understand the following before you submit your order by checking all the boxes below.

I have read the RightEye Sensorimotor Implementation Guide located here, and understand the ideal workflow for RightEye Sensorimotor includes two systems, one located in a pre-test area for screening, and one in an exam room for a comprehensive examination when medically necessary. I understand by using only one system, my outcomes may be different than advertised by RightEye.

I understand RightEye Sensorimotor will only be made available on RightEye VisionTracker2 all-in-one models. If I have an older RightEye hardware model, e.g. RightEye VisionTracker with standalone eye-tracker and Alienware or Zotac brand computer, I will not have access to the RightEye Sensorimotor assessment.

Insurance reimbursement with CPT code is intended for use by eye care doctors located in the United States.