Are You a Candidate for Eyelid Rejuvenation?

We want to be sure you are getting the best possible experience and outcome with your Eyelid Rejuvenation surgery. Please take a moment to fill out this questionnaire regarding your eyelids and vision so that we may help you make an informed decision. Megan, our Oculoplastics Coordinator, will contact you promptly.

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

What is your age group?*

20-39
40-59
60-79
80-100+

Do you feel like your eyelids are interfering with your vision?*

Yes
No

Do you feel like your eyelids make you look tired or aged?*

Yes
No

Do you catch yourself raising your eyebrows to read or see something?*

Yes
No

Do your eyelids feel `heavy` by the end of the day?*

Yes
No

Do you like the appearance of your eyelids?*

Yes
No

Did you know that medical insurance may help cover the cost of Blepharoplasty surgery?*

Yes
No

What is the status of your interest in Blepharoplasty Surgery?*

I am beginning to gather information.
I am ready for a FREE Blepharoplasty consultation.
Sign me up!

Phone

This field is for validation purposes and should be left unchanged.