DIPLOMATE CANDIDACY
Binocular Vision, Perception,
and Pediatric Optometry Section
Candidate Application – Binocular Vision and Perception Emphasis
Date
Name
Office Address
Phone (
)
Email
Home Address
Fax (
)
Phone (
Fax (
)
)
Where do you want mail sent?
Office
Home
ATTACHED IS:
Mode of Practice Information Sheet (Clinical Diplomate only)
Curriculum Vitae [to include: professional education, professional experience (clinical & teaching),
professional affiliations, presentations, publications, honors and awards, community/professional
service]
$100.00 application fee (select payment option below):
Check made out and mailed to the American Academy of Optometry
Online credit card payment (You will be contacted by the AAO office with further
instructions)
I understand that I have five (5) years, which includes the next five (5) Academy meetings, to complete
the requirements for the Binocular Vision and Perception Clinical Diplomate. If I have not successfully
completed these requirements after this time, I will have to completely start over if I plan to continue in
the program.
Signature
Please return this application form, with attachments, to:
Binocular Vision and Perception Section Diplomate Program
American Academy of Optometry
2909 Fairgreen Street
Orlando, FL 32803
Phone: 321.710.EYES (3937)
Fax: 407.893.9890
Email: aaoptom@aaoptom.org
Binocular Vision
MODE OF PRACTICE INFORMATION
Approximately how many of the following types of diagnostic evaluations do you participate in each
month?
Perform yourself
Supervise student
Visual skills / asthenopia
Strabismus / amblyopia
Visual perceptual
Pediatric primary care
Approximately how many of the following types of diagnostic evaluations have you performed in the
last two years?
Perform yourself
Supervise student
Visual skills / asthenopia
Strabismus / amblyopia
Visual perceptual
Pediatric primary care
Approximately how many of the following types of patients (not visits) do you currently have enrolled in
a vision therapy program?
Vision Therapists
Perform Therapy
Trains in your
Supervise Clinician
Yourself
Office
Visual skills / asthenopia
Strabismus / amblyopia
Visual perceptual
Approximately how many vision therapy patients have you trained in the last two years?
Perform Therapy
Therapist Trained Supervised
Yourself
in Your Office
Student clinician
Visual skills / asthenopia
Strabismus / amblyopia
Visual perceptual