Δ 1 2 3 4 5 URLThis field is for validation purposes and should be left unchanged.Personal InformationName(Required) First Last Email(Required) College Registration Number(Required)Phone Number(Required)Date of Birth(Required) Month Day Year Gender(Required)FemaleMaleNon-BinaryPrefer not to sayHome Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please select where Association mail should be sent.(Required) Home Address Practice Address Languages SpokenPlease select all languages in which you are fluent(Required) Arabic Armenian Bengali Burmese Cantonese Croatian Dutch English Farsi Filipino Finnish French German Greek Gujarati Hebrew Hindi Hungarian Italian Japanese Korean Kutchi Mandarin Polish Portuguese Punjabi Russian Sign Language Singhalese Slovak Spanish Swahili Tamil Ukrainian Urdu Vietnamese Yiddish Other Other LanguagesOutreach and Community and Professional AffiliationsAre you a member of a local Society Group/Chapter?(Required) Yes No Are you willing to speak on radio, television, or to a print journalist about optometric issues?(Required) Yes No Please specify the society or group:Are you interested in participating in political advocacy for the profession? (Ex: Contact your MPP or participate in a political fundraiser?)(Required) Yes No Are you willing to participate on behalf of the OAO in community events such as health fairs, presentations to local groups, schools, or companies?(Required) Yes No What community club or professional association do you belong to? Education and TrainingWhere did you obtain an Accredited Professional Optometric Degree?University of Waterloo, ON, CANUniversity of Montreal, Ecole d Optometrie, QC, CANInter American University of Puerto Rico, School of Optometry, PR, USAIllinois College of Optometry, Il, USAIndiana University, School of Optometry, IN, USAMassachusetts College of Pharmacy and Health Sciences, School of Optometry, MA, USANew England College of Optometry, MA, USANova Southeatern University, FL USAMichigan College of Optometry at Ferris State University, MI, USAMidwestern University Arizona College of Optometry, AZ, USANortheastern State University Oklahoma College of Optometry, OK, USANova Southeastern University, College of Optometry, FL, USAOhio State University, College of Optometry, OH, USAPennsylvania College of Optometry at Salus University, PA, USAPacific University, College of Optometry, OR, USASouthern California College of Optometry at Marshall B. Ketchum University, CA, USASouthern College of Optometry, TN, USAState University of New York, State College of Optometry, NY, USAUniversity of Alabama at Birmingham School of Optometry, AL, USAUniversity of California, Berkeley, School of Optometry, CA, USAUniversity of Houston, College of Optometry, TX, USAUniversity of Missouri, St. Louis, College of Optometry, MO, USAUniversity of the Incarnate Word Rosenberg School of Optometry, TX, USAWestern University of Health Sciences College of Optometry, CA, USAChicago College of Optometry, Midwestern University, IL, USAUniversity of Detroit Mercy, School of Optometry, MI, USAInternationally TrainedGraduating YearList any Degrees and Professional Designations (eg FAO, MSc, etc) BSc — Bachelor of Science BMSc — Bachelor of Medical Sciences MSc — Master of Science PhD — Doctor of Philosophy DSc — Doctorate of Science MBA — Master of Business Administration FAAO — Fellow, American Academy of Optometry FCOVD — Fellow, College of Optometrists in Vision Development FIAO — Fellow, Int’l Acad. Orthokeratology ABO Diplomate — American Board of Optometry Residency-Trained Optometrist Fellow — Scleral Lens Society MOptom — Master of Optometry BOptom — Bachelor of Optometry MCOptom — Member, College of Optometrists (UK) FRCS / FRCSEd — Fellow, Royal College of Surgeons FICO — Fellow, Int’l Council of Ophthalmology CAE — Certified Association Executive MOpth — Master of Ophthalmology MBCO — Member, BC College of Optometrists P.Eng. — Professional Engineer RO — Registered Optician Other / Unknown Select All Practice Information: GeneralBusiness/Practice Name(Required)Practice Address(Required) Street Address Address Line 2 City/Town AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Number(Required)Fax NumberPatient and Public ReferralConsent to receive referrals(Required)OAO receives calls from the public inquiring about services provided by optometrists. Would you like OAO to refer patient/public inquiries to you in your practice when asked for an optometrist that provides specific services or speaks a certain language? Yes No Practice Information: Available FacilitiesSelect all services offered by this practice(Required) Advanced Dry Eye Therapy Glaucoma Care Home Visits Infant Examinations (6-24 mos) Laser Refractive Pre/Post-Operative Care Low Vision Low Vision Assistive Devices Program (ADP) Authorizer Mentally/Developmentally Challenged Adult Care Mentally/Developmentally Challenged Child Care Myopia Management Occupational Safety Physically Challenged Patient Care Pre-School Children Examinations (2-5 yrs) Specialty Contact Lenses Sports Vision Vision Therapy/Binocular Vision Training Visits to Institutions Visual Perception Testing Select AllSelect all available facilities at this practice(Required) Corneal Topography Digital Retinal Imaging/Fundus Photos Dispensing Office Eye See...Eye Learn Practice Handicapped Washroom Heidelberg Retinal Tomography (HRT) Optical Coherence Tomography (OCT) Ramps Wheel Chair Accessible Entrance Wheel Chair Accessible Examination Room Visual Fields - Automated Other Select AllPlease specify other available facilitiesSpecialty contact lenses offered at this practice Contacts for Keratoconus Hard Contacts/Rigid Gas Permeables Orthokeratology/Corneal Refractive Therapy Scleral Lenses Select AllAdditional PracticesAdd Another Practice <div class="repeater-field-header"> <div class="repeater-field-header-title">Additional Practice <span class="repeater-field-header-count">1</span></div> <div class="repeater-field-header-acctions"> <ul> <li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li> <li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li> </ul> </div> </div> Business/Practice NamePractice Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Clinic PhoneSelect all services offered by this practice Advanced Dry Eye Therapy Glaucoma Care Home Visits Infant Examinations (6-24 mos) Laser Refractive Pre/Post-Operative Care Low Vision Low Vision Assistive Devices Program (ADP) Authorizer Mentally/Developmentally Challenged Adult Care Mentally/Developmentally Challenged Child Care Myopia Management Physically Challenged Patient Care Physically challenged patient care Pre-School Children Examinations (2-5 yrs) Specialty Contact Lenses Sports Vision Visits to Institutions Vision Therapy/Binocular Vision Training Visual Perception Testing Select AllSelect all available facilities at this practice (rep) Corneal Topography Digital Retinal Imaging/Fundus Photos Dispensing Office Eye See...Eye Learn Practice Handicapped Washroom Heidelberg Retinal Tomography (HRT) Optical Coherence Tomography (OCT) Ramps Wheel Chair Accessible Examination Room Wheel Chair Accessible Entrance Visual Fields - Automated Other Select AllPlease specify other available facilitiesSpecialty contact lenses offered at this practice Contacts for Keratoconus Hard Contacts/Rigid Gas Permeables Orthokeratology/Corneal refractive therapy Scleral lenses Select All Applicant ConsentConsent to receive electronic communications(Required) I agree to receive electronic communications from OAO I do not agree to receive electronic communications from OAO ConfirmationBy submitting this form, I hereby apply for a membership in the Ontario Association of Optometrists (OAO). I agree to abide by its constitution, bylaws, and Code of Ethics for OAO Members, and to promptly advise the OAO of any change in practice location. As an OAO member, I understand and agree that my name, practice address(es) and practice phone number will be posted on the OAO website for public access through the 'Find an Optometrist' program. Unless otherwise stated, information (other than noted above) requested in the following pages is kept confidential and will be used by OAO solely to: Develop policy and proposals advocating for the profession with the Ontario government; Evaluate and expand member resources, benefit programs and services.
