Fork in the Road Vision Rehabilitation Services, LLC

LowVisionSimulators@Gmail.com      WWW.LowVisionSimulators.com

5141 Door Drive, Madison, WI 53705-4752 USA Voice/FAX: 608-233-3464 

Qty

Item #

Low Vision Simulators

Price (USD)

Total

 

101

Central scotoma: Visual acuity of 20/400 (6/120)*

$33

 

 

102

Central scotoma: Visual acuity of 20/200 (6/60

$33

 

 

103

Tunnel vision: 10° visual field & visual acuity of 20/80 (6/24)*

$33

 

 

104

Tunnel vision: 20° visual field & no impairment of visual acuity

$33

 

 

105

Diabetic retinopathy: Visual acuity of 20/100 6/30)*

$33

 

 

106

Impaired Acuity: Visual acuity of 20/80 (6/24)*

$29

 

 

107

Impaired Acuity: Visual acuity of 20/200 (6/60)*

$29

 

 

108

Impaired Acuity: Visual acuity of 20/400 (6/120)*

$29

 

 

109

Impaired Acuity: Visual acuity of 20/800 (6/240)*

$29

 

 

110

Right Homonymous Hemianopsia with no impairment of acuity

$39

 

 

111

Right Homonymous Hemianopsia with 20/200* (6/60) acuity

$39

 

 

112

Left Homonymous Hemianopsia with no impairment of acuity

$39

 

 

113

Left Homonymous Hemianopsia with 20/200* (6/60) acuity

$39

 

 

201

Canvas Bag w/ Fork in the Road logo

$12

 

 

609

Dictionary of Eye Terminology 5th ed

$32.95

 

 

 

RUSH (if you want it shipped in fewer than 5 biz days) add 15%

 

 

 

Wire transfer/bank fees (for international funds – sometimes --  talk to me if you will using a bank-to-bank fund transfer)

$15

 

 

Subtotal

 

 

Sales Tax (only if you are in Wisconsin, USA)

 

                                           Shipping in the US lower 48

 

1 simulator

$6.50

 

2-4 simulators

$7.50

 

5-8 simulators

$9.95

 

9-13 simulators

$10.95

 

14-19 simulators

$11.95

 

20-30 simulators

$15.95

 

31-40 simulators

18.95

 

Over 40 simulators

Call or email for quote

Dictionary of Eye Terminology:  1 copy $6.50  Add $1.50 for each additional copy. (No extra charge for Dictionary shipping if purchased with 2 or more simulators)

Alaska, Hawaii and outside the US -- Call or email for a quote

 

Total  (all amounts USD)

 

Sold To

  Date_______________________                      P.O. # _____________________

  Name______________________________________

  Organization/Company________________________________

  Address_____________________________________________

  Address_____________________________________________

  City__________________________ State/Prov________ Postal___________

  Country_____________________   Email_____________________________

  Phone ___________________________ Fax __________________________

  *********** Ship To (if different) ***********

  Name ________________________________________

  Organization/Company ____________________________________________

  Address_________________________________________________________

  Address_________________________________________________________

  City ____________________________State/Prov _____Postal

  Country _____________________ Phone ______________________________

  Payment (circle):  Purchase Order         *         Check

  Credit Card: Visa  *           MasterCard  *         

  Number ____________________________________________________

  Expires ______________Signature_______________________________ 

Checks payable to: Fork in the Road Vision Rehabilitation Services, LLC

Fork in the Road EIN#: 20-1156413

 

5141 Door Drive, Madison, WI 53705-4752 USA

Voice/FAX: 608-233-3464

LowVisionSimulators@Gmail.com      WWW.LowVisionSimulators.com

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