1. Patient Details

Your full name

Your email

Date of birth

WhatsApp number

2. Treatment Goals & Concerns

What are your expectations and concerns? (Select all that apply)
Double eyelids / lack of creaseDesire for larger or more defined eyesImpaired vision due to excess skinPuffy or swollen eyelidsHeavy eyelids / discomfortTearing or lacrimal gland protrusionnoneothersOthers (please specify):

3. Photo & Video Upload

Please upload clear close-up images of your eyes:
(Files: jpg | png | gif, not larger then 1 MB)
1. Eyes open (neutral position)

2. Eyes closed

3. Looking up

4. Looking down

Video:
Short video of opening and closing your eyes (blinking)

4. Medical Allergies

Do you have any known medical allergies?
(e.g. Latex, Lidocaine/Xylocaine, medications)

5. Cosmetic Ingredient Sensitivity

Please tick if you have any known sensitivity or allergy to the following:
Aloe VeraSulphurProgesteroneGlycolic AcidSunscreen (SPF Products)Vitamin C or E (Topical)Retin-A / RetinolnoneothersIf others (please specify):
Any other cosmetic ingredients or skincare products that caused irritation or allergic reactions:

6. Current Medications

List all medications you are currently taking
(Including prescription, over-the-counter, supplements, herbs, aspirin, ibuprofen, etc.)

7. Medical History

Please tick if you have any history of disease
Thyroid DiseaseHeart FailureArrhythmiaBleeding / Hemorrhagic DisorderDiabetesHypertension (High Blood Pressure)Cerebrovascular Disorder (Stroke)RosaceaPemphigoidHerpesDepressionnoneothersOthers (please specify):
Any other medical conditions, chronic illnesses, or relevant health concerns:

8. Additional Health Information

Please indicate if you have any of the following:
Anaesthetic history (allergy or resistance)High blood pressureLow blood pressureHeavy alcohol consumptionDrug historyBleeding tendency / prolonged bleedingPrevious surgery (eyes or other)Abnormal scarring (keloid / hypertrophic)AsthmanoneothersOthers (please specify):
Any other relevant medical history, chronic conditions, current medications, or known sensitivities that may affect your treatment.

9. Previous Cosmetic Procedures (Eye Area)*

Have you had any previous cosmetic or surgical procedures in the eye (periorbital) area?
yesnoIf yes, please provide details:
(Type of procedure, approximate date, clinic/doctor, any complications or outcomes)

10. Comments Section

Additional comments or questions (optional):

Declaration & Consent
By submitting this form, you confirm that all information provided, including details of previous procedures and medical history, is true, accurate, and complete to the best of your knowledge.

Failure to disclose complete and accurate information may affect the safety, suitability, and outcome of your treatment.