The following document and form are for patients who have arranged a Tele-Optometry consult with our office.

The Optometrists at Simcoe Optometric Clinic are providing virtual tele-consults where appropriate, to allow for safe and effective delivery of eye care.

Before submitting the Consent to Tele-Optometry form, be sure to read the following Consent to Tele-Optometry Services document (safe .pdf file).  Please contact our office with any questions or concerns you may have regarding Tele-Optometry services from our office before submitting this form.

Please note that we will not be able to begin your Tele-Optometry consult until we have received the following consent form.


Tele-Optometry Consent Form

please complete and submit in order to proceed with your Tele-Optometry consult.
  • I confirm that i have read the *Consent to use Electronic Communications to provide Tele-Optometry Services* document and understand and accept the risks and limitations associated with the receipt of Tele-Optometry services; I have been advised of and understand the nature, material risks, consequences, side effects, expected benefits of and alternatives to Tele-Optometry services; I will abide by the Patient Responsibilities set out in the Consent to Tele-Optometry Services sheet; I have had the opportunity to ask questions regarding Tele-Optometry services and have received answers to all of my questions; I understand that I may withdraw my consent to Tele-Optometry services at any time;