Form – Optometrist – Vision Therapy Canada

Greetings Colleague!

Your patient, , has applied for financial assistance through COVTR’s Betty Fretz Scholarship Fund for your recommended in-office Vision Therapy Program.

The Betty Fretz Scholarship Fund was created in 2018 by COVT&R as a means to offer financial aid to those patients who would otherwise not be in a position to receive the care they require through in-office Vision Therapy.

Before your patient’s application can be processed, we need some information from you!

The person named above is my patient or is the parent/guardian of my patient.
I have recommended in-office Vision Therapy as the best treatment option for the above named patient.
I have reasonable belief that the above named patient is in need of financial assistance and may otherwise not be in a position to receive Vision Therapy as a treatment avenue.

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- I certify that all of the above statements are true and accurate. I understand that falsification will revoke my VTC membership and any funds awarded may be reassessed and/or withdrawn and/or be returned fully by me.
What is the total cost of the in-office Vision Therapy program you have offered to the above named patient?
What is the additional scholarship funding your practice will donate to “top up” the financial assistance for your patient? Please enter an amount from $0 up to your desired donation.
Thank you for your time in completing this form on behalf of your patient, . The award selection committee for the Betty Fretz Scholarship Fund will review this application with other eligible applications and once the committee has completed the selection process and your patient, is awarded, both you and your patient will be informed of the decision for financial assistance, including the amount awarded and the date the award will be disbursed.

Thank you for your continued support of Vision Therapy in Canada!
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