Forms & Applications

Forms

Application for Ophthalmic Screening Program

Sorry, your request could not be submitted. Please see fields below

CVO Member Information

First Name*

First name is required

Last Name*

Last name is required

Licence #*

Valid license # is required

Email*

Valid Email address is required

Participating Veterinarians

One of these options must be selected.

The procedures relating to this program will be performed by (please check all that apply):*

Myself, as a diplomate of the American College of Veterinary in Ophthalmology
Another veterinarian who is a diplomate of the American College of Veterinary in Ophthalmology, and has obtained a short-term licence to practice in Ontario

Veterinarian Name

Add another veterinarian

By one or more of my auxiliaries, who will be under immediate supervision

Location of Ophthalmic Screening Program

A separate request must be submitted for each location.

Name of Facility or Building*

Facility name is required

If location is an accredited facility, please provide the approved facility name, not the professional corporation name. If the location is un-accredited, please provide the business name.

Address*

Facility address is required

City*

Facility City is required

Province

Is this an accredited facility?*

A facility holding a valid Certificate of Accreditation from the College.

YesNo

Facility accreditation status is required

Program Date(s)

Is this a single-day or multi-day program?*

If applying for a single-day: the start date is the day the program is held, the end date is the following day; If applying for a multi-day: the start date is the day the first program is held, the end date is the day following the last program that is held, up to a maximum of 6 months

Single-dayMulti-day

Date*

Today

Start date is required

End Date*

Today

End date is required

Your program dates cannot exceed a period of 6 months.

Your program start date must precede the program end date.

Please note: If you are applying for multiple program dates, they may not span a period greater than 6 months.

Sponsoring Veterinarian Declaration

You must agree to all declarations in order to apply.

I, the sponsoring veterinarian, currently licensed with the College of Veterinarians of Ontario, hereby confirm that:*

I am a licensed member of the College of Veterinarians of Ontario and agree to abide by the College's Position Statement on Ophthalmic Screening Programs and all other relevant legislation.

Signature*

By checking this box I confirm that I am the licensed member submitting this application. I confirm that the information entered on this form is true and correct. I understand that it is professional misconduct to submit false or misleading information to the College (as per Regulation 1093 ss 38.1)

Signature is required

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