Blepharoplasty Consultation Form
Step 1 of 10
1. First, please tell us a bit about yourself.
Date of Birth (MM/DD/YYYY):
Date Format: MM slash DD slash YYYY
2. Have you ever had cosmetic surgery before?
Have you ever had cosmetic surgery before?
2a. Please specify:
3. Do you have any pre-existing medical conditions?
Do you have any pre-existing medical conditions?
3a. Please provide more information:
Please provide more information:
4. Do you smoke?
Do you smoke?
5. When would you like to get the procedure done?
Within what time frame are you looking to have the abdominoplasty performed?
Within the next 3 months
Within the next 6 months
Within a years time
Undecided, only inquiring at this time
6. What is your motivation for eyelid surgery?
Please check all that apply
I have drooping upper eyelids
I have large bags under my eyes
I have dark circles under my eyes
8. What is the best time of day to book your consultation?
What is the best time of day to book your consultation?
9. How can we reach you?
What is your preferred method of contact?