Welcome to The Vision Center at Seaside Farms
Thank you for choosing Dr. Bodkin or Dr. Boiwka for your eyecare needs. We are delighted to have you as a patient and look forward to caring for your eyes. Please take a moment to complete the following information. If you would prefer to print the form out and bring it with you, send an email to info@seasidevision.com and we will send it to you. You can visit http://www.seasidevision.com/services/eye-examinations.html to learn what will occur during your eye exam. If you have any questions, please do not hesitate to call us at 843-388-6200 or email us at info@seasidevision.com
Salutation
First Name *
Middle Name
Last Name *
Email Address *
Sex
Street Address
City
State
Zip Code
Social Security Number
Last 4 digits only
Date of Birth
Home Phone
include area code
Cell Phone
include area code
Emergency Contact Name
Emergency Contact Phone Number
include area code
Insurance Information
If you do not plan to use insurance for your visit, you can skip this section. If you are filling this form out in our office, you can skip this section.
Insurance Company Name
Insurance ID Number
Patient's Relationship to Insured
Clear selection
Patient's Health History
Primary Care Physician's Name
Primary Care Physician's Address
Primary Care Physician's Phone Number
include area code
When was your last Eye Exam
When was your last health exam
Past Surgeries
Current Medications
Current Eye Drops
Medications That Cause Sensitivities/Allergies
Eye History
Check all that apply
General Health History
Check all that apply
Family History
Check all that apply
Spectacle Lens History
Do you currently wear glasses?
If yes, since when?
Type of Glasses
Glasses Owned
Have you had trouble in the past with glasses?
If yes, what kind of trouble?
What are you doing to protect your eyes from UV?
What are you doing to protect your eyes from harmful blue light from electronic screens?
Contact Lens History
Are you interested in trying contact lenses?
Have you ever tried to wear contact lenses?
If yes, what was your reason for stopping?
Do you currently wear contact lenses?
Type/Brand of contact lenses?
How many hours a day do you wear your lenses on average?
How many days a week?
How often do you replace your lenses?
Do you sleep in your contact lenses?
If yes, how often?
What solution do you use to clean your contact lenses?
Social History
What is your current occupation?
Who is your employer?
Do you:
check all that apply
What are your hobbies or interests?
How did you hear about us? *
Check all that apply
Required
If you checked 'Family or Friend' above, what is their name?
First and Last
Submit
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