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
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Middle Name
Your answer
Last Name
Your answer
Email Address
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Sex
Street Address
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City
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State
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Zip Code
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Social Security Number
Last 4 digits only
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Date of Birth
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Home Phone
include area code
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Cell Phone
include area code
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Emergency Contact Name
Your answer
Emergency Contact Phone Number
include area code
Your answer
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
Your answer
Insurance ID Number
Your answer
Patient's Relationship to Insured
Patient's Health History
Primary Care Physician's Name
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Primary Care Physician's Address
Your answer
Primary Care Physician's Phone Number
include area code
Your answer
When was your last Eye Exam
Your answer
When was your last health exam
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Past Surgeries
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Current Medications
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Current Eye Drops
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Medications That Cause Sensitivities/Allergies
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Eye History
Check all that apply
General Health History
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Family History
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Spectacle Lens History
Do you currently wear glasses?
If yes, since when?
Your answer
Type of Glasses
Glasses Owned
Have you had trouble in the past with glasses?
If yes, what kind of trouble?
Your answer
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?
Your answer
Do you currently wear contact lenses?
Type/Brand of contact lenses?
Your answer
How many hours a day do you wear your lenses on average?
Your answer
How many days a week?
How often do you replace your lenses?
Your answer
Do you sleep in your contact lenses?
If yes, how often?
Your answer
What solution do you use to clean your contact lenses?
Your answer
Social History
What is your current occupation?
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Who is your employer?
Your answer
Do you:
check all that apply
What are your hobbies or interests?
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How did you hear about us?
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Required
If you checked 'Family or Friend' above, what is their name?
First and Last
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