Eye Gaze Communication Board Request
Please complete this request to help us provide the most suitable eye gaze communication board for your client or organization.
Requester Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Device User's Name
*
First Name
Last Name
Relationship to Device User
*
Self
Parent/Guardian
Therapist
Educator
Other
Primary Communication Needs
*
Express wants/needs
Social interaction
Academic participation
Medical communication
Other
Preferred Board Language(s)
*
English
Spanish
French
Other
Accessibility/Environment Needs
Adjustable mount required
Portable use
Wheelchair mounting
Classroom use
Home use
Other
Board Layout Preference
*
Simple (fewer cells, larger images)
Standard (moderate number of cells)
Complex (many cells, more vocabulary)
No preference
Urgency/Timeline for Board Delivery
*
Please Select
As soon as possible
Within 2 weeks
Within 1 month
Flexible/No rush
Additional Notes or Special Requests
Submit Request
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