Your email
Your full name
Date of Birth
WhatsApp Number
What is your Expectation and Needs (by symptoms)? Double FoldsLarger Eyes?Problem with seeing due to skin laxitySwelling appearance of eyelidDiscomfort/Heavy/Foreign body SensationTear (Lacrimal Gland Protrusion)
Send us your Clear Close up photo 1. Both eyes open normal
Send us your Clear Close up photo 2. Both eyes closed normal
Send us your Clear Close up photo 3. Both eyes looking up
Send us your Clear Close up photo 4. Both eyes looking down
Send us your clear close up video, open and close both eyes (Blink)
Medical Allergies (Latex and Xylocaine)
Cosmetic Ingredients Sensitivity or Allergies Aloe VeraSulphurProgesteroneGlycolicSunscreenVitamin C or E TopicalRetin A/Retinol
List all prescription and over the counter medications you are currently taking (Including Aspirin, Ibuprofen, Herbs & Vitamins)
Please tick if you have any History of Disease Thyroid DiseaseHeart FailureArryhtmiaHemorrhagic DiseaseDiabetesHypertensionCerebro Vascular Disorder (Stroke)RosaceaPemohigoidHerpesDepression
Do You have? Anaesthetic History (Any Allergic Reaction, Resistance)High Blood PressureLow Blood PressureHeavy Alcohol DrinkerDrugs HistoryBleeding Tendency (Prolong Bleeding History)Surgery History within the eyes or any other partScar History (Hypertrophic/Keloid)Asthma
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