Eye See…Eye Learn® Form

ESEL Doctor Agreement

Please review the Doctor Agreement below and confirm the information provided before submitting.

Your Information

Terms & Conditions*

  • I agree to provide OHIP insured comprehensive eye examinations to eligible Junior Kindergarten (JK) and Senior Kindergarten (SK) students.
  • I agree to promote and provide complimentary glasses, if prescribed, to eligible patients.
  • I agree to waive all dispensing fees.
  • I agree to submit the data (on a monthly basis) using the on-line portal provided by OAO and maintain any necessary forms provided by the ESEL program.
  • I agree to perform the eye exam and prescribe the glasses at the same location to an eligible patient.
  • I agree to use exclusively the OAO/ESEL vendor products as outlined by the OAO and ESEL Program.
  • I will inform OAO if I change offices, move or lease the ESEL Program.
  • If I leave the ESEL Program, I will remove all marketing materials and not promote myself or practice as ESEL Program.
  • Allow OAO to advertise the enrolment in the ESEL Program.
  • Must give notice to OAO of any changes to participating in the ESEL Program.

Fields marked * are required.