Blepharoplasty Informed Consent Form
Please complete this form to provide your informed consent and necessary medical details before your blepharoplasty procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Do you have any known allergies?
*
No known allergies
Yes, medication allergies
Yes, latex allergy
Yes, other (please specify)
Are you currently taking any medications?
*
No
Yes, prescription medications
Yes, over-the-counter medications
Yes, herbal supplements
Other (please specify)
Have you had any prior eye or eyelid surgeries?
*
No prior surgeries
Yes, upper eyelid surgery
Yes, lower eyelid surgery
Yes, other eye surgery
What is your primary reason for seeking blepharoplasty?
*
Cosmetic (appearance improvement)
Functional (vision impairment)
Medical recommendation
Other (please specify)
Please acknowledge the following risks and alternatives have been explained to you by your provider:
*
Bleeding or infection
Scarring
Dry eyes or irritation
Possible need for revision surgery
Non-surgical alternatives discussed
Signature
*
Submit Consent
Submit Consent
Should be Empty: