O-7, r. 14 - Regulation respecting the standards for the issue and holding of the permit authorizing an optometrist to administer and prescribe medications for therapeutic purposes and provide eye care

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 1)

APPLICATION FOR THE PERMIT AUTHORIZING AN OPTOMETRIST TO ADMINISTER AND PRESCRIBE MEDICATIONS FOR THERAPEUTIC PURPOSES AND PROVIDE EYE CARE

(s. 1)

I, the undersigned _________________________________ residing at ___________________________, hereby declare the following:

(1) I am entered on the roll of the Ordre des optométristes du Québec;

(2) my professional domicile is located at _____________________________________ and I also practise at __________________________________;

(3) I have enclosed the documents establishing that my training complies with the training prescribed by the Regulation respecting the standards for the issue and holding of the permit authorizing an optometrist to administer and prescribe medications for therapeutic purposes and provide eye care (chapter O-7, r. 14);

(4) I am applying to the board of directors for the permit authorizing me to administer and prescribe medications for therapeutic purposes and to provide eye care, in accordance with the provisions of the Optometry Act (chapter O-7), of the Regulation respecting the standards for the issue and holding of the permit authorizing an optometrist to administer and prescribe medications for therapeutic purposes and provide eye care and of the Regulation respecting the medications that may be administered an optometrist and prescribed for therapeutic purposes by an optometrist and respecting the eye are that may be provided by an optometrist (chapter O-7, r. 11).

Member’s signature ________________________________

Date ________________________________

O.C. 1024-2003, Sch. I.