Consent Form

Thank you for your interest in the BrainPort Vision Pro oral electronic vision aid. The BrainPort Vision Pro is an oral electronic vision aid that provides electro-tactile stimulation to aid profoundly blind patients in orientation, mobility, and object recognition as an adjunctive device to other assistive methods such as the white cane or a guide dog. Caution: Federal law restricts this device to sale by or on the order of a physician.

The following questions will help us determine whether the BrainPort Vision Pro device is right for you.  The questions labeled with a “*”require an answer.  Individuals under 18 years old and those who have a legal guardian may need their parent or legal guardian to complete the questionnaire. This questionnaire will take you 5 – 10 minutes to complete. You will be contacted by a training specialist to review your questionnaire and arrange a time/location for training.

By selecting “Next” below, you are indicating that you, your parent if you are under 18 years old, or your legal guardian if applicable, have read and understood this consent form.  By selecting “No Response” above, you can withdraw and no data will be saved.  This exit link is at the top-right corner on every page of this questionnaire.

Please save a copy of this page for your records.

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