Patient Forms & New Patient Resources in Myrtle Beach

Access our patient forms that you can fill out before your next visit to Vision Source at Seaside Eye Associates in Myrtle Beach.

New Patient Form

General Information

Name

First

Last

Preferred Name

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Type

Phone 2 Type

Email Address

Preferred Contact Method

Patient Social Security Number (last 4 digits only!)

Date of Birth

Gender

Female Male

Occupation/
Employer

Marital Status

Preferred Language

Race

Ethnicity

Emergency Contact Person

Emergency Contact
Person Phone Number

Insurance Information

Vision Insurance

Vision Insurance Member Name

Vision Insurance Member
Identification Number

Vision Insurance Member
Date of Birth

Primary Medical Insurance

Primary Member Name

Insurance Identification Number

Insurance Policy#/Group ID#

Primary Member
Date of Birth

Primary Member Social Security Number

Primary Member Employer

Your Relationship to Primary Membe

Secondary Medical Insurance

Secondary Medical Insurance Name

Secondary Medical Insurance Identification Number

Secondary Medical Insurance Policy#/Group ID#

Secondary Medical Insurance
Date of Birth

Secondary Medical Insurance Social Security Number

Your Relationship to Secondary Medical Insurance Member

Eye History

Date of Last Eye Exam

Currently Wear Glasses?

YesNo

Currently Wear Contacts?

YesNo

Reason for Today's Visit

Have you or a family member experienced, or been treated for, any of the following? Circle all that apply.

Cataracts

YesNoFamily

Crossed Eye

YesNoFamily

Glaucoma

YesNoFamily

LASIK or RK

YesNoFamily

Lazy Eye

YesNoFamily

Macular Degeneration

YesNoFamily

Retinal Detachment

YesNoFamily

Are you currently experiencing, or have experienced, any of the following? Check all that apply.

Blurry Vision (near or distance)BurningHeadachesDischargeDouble VisionDrynessExcess Tearing/WateringEye InfectionEye Pain or SorenessFloaters or SpotsHalosHeadachesItchingLight FlashesLight SensitivityRednessSandy or Gritty Feeling

Medical History

Have you or a family member experienced, or been treated for, any of the following? Select all that apply

AIDS/HIV

YesNoFamily

Allergies

YesNoFamily

Arthritis

YesNoFamily

Asthma

YesNoFamily

Blood/Lymph Disorder

YesNoFamily

Cancer

YesNoFamily

Diabetes

YesNoFamily

Ears, Nose, Throat Conditions

YesNoFamily

Gastrointestinal Conditions

YesNoFamily

Heart Disease

YesNoFamily

High Blood Pressure

YesNoFamily

High Cholesterol

YesNoFamily

Kidney Disease

YesNoFamily

Lupus

YesNoFamily

Neurological Conditions

YesNoFamily

Psychiatric Disorder

YesNoFamily

Seizures

YesNoFamily

Skin Conditions

YesNoFamily

Skin Conditions

YesNoFamily

Stroke

YesNoFamily

Thyroid Dysfunction

YesNoFamily

Current Medications (prescription and over-the-counter and dosage)

Medication Drug Allergies

Height

Weight

Are you pregnant or nursing?

Do you smoke?

Have you ever smoked?

Thank you. We'll connect with you shortly to confirm your appointment.

You are missing required fields.

Dynamic Error Description

There was an error processing this form.

Quick Links

About Us
Our Services
Meet the Team
Testimonials
Contact Us

Helpful Articles

Vision Therapy: Conditions

Post-Concussion Syndrome

Comprehensive Eye Exam

Ortho K

Demodex

What to Expect During an Eye Exam

Refraction Test

Presbyopia

Corneal Refractive Therapy

Senior Care

Neuro-Optometric Rehabilitation

Keratoconus and Your Treatment Options

Scleral Lenses

Types of Daily Contact Lenses

Multifocal Contact Lenses

Specialty Contact Lenses

Post-Surgical Contact Lenses

Hybrid Contacts

Colored Contacts

Understanding Computer Vision Syndrome

Considering Your Face Shape When Choosing Eye Glass Frames

Lens Technology

Avulux

Stellest Lenses

EnChroma Lens Technology

Ray-Ban Meta Glasses

Nuance Audio Glasses

Best Foods for Eye Health

How Exercise Benefits the Eye

Importance of Routine Eye Exams

How Your Eyes Change with Age

Eye Safety Tips

Seasonal Allergies And The Eyes

Common Eye Disorders Explained

Eyelid Hygiene

Benefits of LASIK

Implantable Contact Lenses

Limbal Relaxing Incisions

Which Patients are Good Candidates for Premium IOL

Can Diet Reverse Diabetic Retinopathy

Eye Disease Treatment

Why Should You Consider Eyelid Rejuvenation

LASIK Surgery

Overview of Visian ICL

Latisse Eyedrops

EyePromise

MacuHealth

OCuSOFT

MiSight

iLux

Ocular Aesthetics

Atropine Drops

LACRIFILL® (Punctal Plugs)

Tyrvaya for Dry Eye Relief

Am I a candidate for LASIK?

LASIK Co-Management

CLE

Surgical Co-Management

Cataract Surgery Co-Management

Diabetic Related Eye Exams

Overview of Common Ocular Diseases

Dry Eye Advanced Diagnostic Testing

Optos

Blephex

Visual Field

Lumenis Optilight IPL

TearCare: Understanding Dry Eye and Its Causes

Medmont Topography

Optical Coherence Tomography

MiBo Thermoflo

Optikam

Low Level Light Treatment

TempSure Envi

Tonometer

Lipiflow

Optomap

Retinal Imaging Testing

Newton

Nuance Audio Frames

All Eye Care Services

Find personalized eye care excellence with our comprehensive services. From eye exams to advanced diagnostics, trust us for all your vision needs.

Keep In Touch

For non-urgent questions or to learn more about our services, contact us today!

Patient Forms

New Patient Form

General Information

Insurance Information

Eye History

Medical History

All Eye Care Services

Keep In Touch

Contact Information

Hours of Operation

Patient Forms

New Patient Form

General Information

Insurance Information

Eye History

Medical History

All Eye Care Services

Keep In Touch

Contact Information

Hours of Operation

Login

OR

Save Search

Saved Searches

Modal title

Update Profile