Trade Name Application

Additional Applicants
Attach additional applicant(s) information, if necessary

PRACTICE LOCATION(S). Please list all anticipated practice locations where application is being made for approval to use the trade or assumed name:

Do you intend to practice through virtual or remote means?

If yes provide a description and describe how you intend to comply with the standards required by K.A.R. 65-8-1:

65-8-1. Examination and adaptation procedures. (a) The following minimum standards for examination procedures shall be performed by a licensee during any examination conducted to determine if a prescription for corrective lenses should be provided:
(1) visual acuity testing of each eye at far and nearpoint;
(2) external examination;
(3) refraction (objective and subjective);
(4) coordination testing;
(5) ophthalmoscopy;
(6) biomicroscopy; and
(7) Tonometry (if the patient is age 25 or over).
(b) In addition to the minimum standards in (a), the following additional minimum standards for procedures shall be performed during any contact lens evaluation:
(1) measurement to determine anterior curvatures of the cornea by use of an instrument capable of producing and providing reliable findings;
(2) evaluation of appropriate eye variables and biomicroscopic evaluation of lid health and corneal integrity;
(3) application of known diagnostic lenses to each eye to include evaluation of acuity, over-refraction, and biomicroscopic evaluation of lens fit with use of chemical dyes, as indicated; and
(4) discussion with the patient of the probable success and risks of contact lens wear.
(c) In addition to the minimum standards for examination and evaluation procedures set out in (a) and (b), the following are additional minimum standards for procedures to be performed during any contact lens adaptation to determine a patient’s first contact lens prescription:
(1) provide patient adequate training in lens care, lens application and removal, lens wear, lens care solutions and products, and proper disinfection procedures;
(2) provide patient adequate training in proper wearing schedule, warning signs and recall intervals;
(3) provide for a minimum of two follow-up visits over a minimum period of the two months prior to determining the contact lens prescription; and
(4) visual acuity testing and biomicroscopic evaluation of each eye with and without lenses at each follow-up visit. (Authorized by K.S.A. 74-1504(a)(6); implementing K.S.A. 1991 Supp. 65-1501; effective May 18, 1992.)

TRADE OR ASSUMED NAME REQUESTED: Please list the trade or assumed name you are requesting and any alternates in order of preference:

Do you intend to practice or are you currently practicing under the name of a professional corporation or professional limited liability company authorized by either KSA 17-2706 or KSA 17-7668? If yes, provide the name of the entity, the owners of the entity (shareholders or members) and all licensees practicing under the name of the entity. Also, provide a copy of the draft or filed articles of incorporation or articles of organization

Articles of Incorporation
Copy of the draft or filed articles of incorporation or articles of organization

*The applicant must also request and obtain a certificate from the Board certifying the individuals to engage in the professional services are duly licensed by the Board.

CERTIFICATION OF APPLICANT(S). By typing their name below, each applicant certifies to the Kansas Board of Examiners in Optometry that each, individually:

Please check all that apply
Has made a reasonable search, including contact with Kansas Secretary of State, review of local telephone books and the approved trade name list (posted on the Board's website), and internet for the present and anticipated practice locations and is unaware of any persons or entity using the trade name or assumed name applied for or a name so similar to the one(s) applied for as to create a potential confusion;

Has obtained permission to practice under an existing trade name as listed above;

He or she intends to actively engage in the practice of optometry under the trade name or assumed name applied for, if approved, within 6 months of approval.

SIGNATURE OF APPLICANT(S). Each applicant listed above must provide an electronic signature by typing their name below.  Applications are approved at board meetings held in January, April, June, and October. There are no exceptions to this schedule.

Perjury statement. I hereby swear or affirm under penalty of perjury that the information given herein is true and correct to the best of my knowledge or belief.


Signature(s) of additional applicant(s)