Eye See…Eye Learn® Form

ESEL Practice Agreement

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

Your Information

First Name

Last Name

Email address

OE Tracking Number

Responsibilities of Participating Practices in ESEL Program*

Using OAO’s online portal, report on a monthly basis the number of Junior Kindergarten (JK) and Senior Kindergarten (SK) students who receive an ESEL eye exam.
Open an account with Essilor and Modern Optical.
Dispense exclusively Essilor lenses and Modern Optical frames to eligible JK and SK students who are prescribed eyeglasses through the ESEL Program.
Waive all dispensing fees.
Purchase and maintain a minimum of 12 children’s frames.
Ensure that the order form is completed in full (including an ESEL Tracking Number) and faxed to Essilor.
Allow only OAO Members to perform ESEL eye exams.
Promote the ESEL program to patients and non-patients.
Give OAO notice of any changes to participating Doctors in the ESEL Program or the Practice.
Participating optometrists and/or practices, that do not comply with all of the program requirements, will be removed from the ESEL Program.

I have the authority to engage this practice in the Eye See... Eye Learn® program. I am aware of the financial costs and accept the terms and conditions as stated below.

Fields marked * are required.

ESEL Practice Agreement

Your Information

Responsibilities of Participating Practices in ESEL Program*

Enrolment not approved

Your Eye See…Eye Learn® enrolment application was not approved.

Reason for decision

Practice Agreement submitted

Your Eye See…Eye Learn® enrolment is not complete yet.

STATUS SUMMARY

Enrolment forms submitted

Your Eye See…Eye Learn® enrolment application is complete and under review.

STATUS SUMMARY

You’re approved to participate

You are now officially participating in the program.

STATUS SUMMARY