School Name: Clinic Date(s):
You MUST provide the following information to have your child participate in the Clinic. If any information is inaccurate or left blank, your child’s eyes will NOT be examined.
Student’s Name: (Please print CLEARLY) Bring Child’s Prescription Glasses to Clinic (if applicable)
Male Female
First Name Middle Initial Last Name
Grade Room # Teacher Student’s Address
I authorize my child to participate in the School Vision Care (SVC) Clinic being held at the school and to dispense a pair of FREE prescription glasses to my child if deemed necessary by the optometrist. I understand that this full eye examination will be charged to my child’s Health Card number. The Ontario Health Insurance Plan (OHIP) will ONLY cover the cost of one (1) full eye examination every twelve (12) months.
I authorize the optometrist to dilate my child’s pupils if clinically required. Yes No
I authorize my child to pick his/her own glasses. Parents are invited to attend. Yes No
Pupil dilation is part of a thorough eye exam; it allows the optometrist to see all the way into the back of the eye. This is accomplished by putting eye drops in the eye. Pupil dilation is not uncomfortable, but the drops take approximately 30 minutes to work and the student may have difficulty in close-up work for the next hour and may experience sensitivity to light, until the drops have stopped working. The odd time the drops can affect distance vision in the same manner.
If my child is prescribed glasses, I want my child’s glasses to be dispensed by a licensed optician at:
The SVC Office (90 Simcoe Street North, Oshawa) OR A school in my area.
It is strongly recommended that a parent/guardian of your child be present when the glasses are dispensed
Parent/Guardian signature (mandatory): Date:
www.schoolvisioncare.ca SVC – 90 Simcoe Street North, Oshawa 905-240-7822