How Old Are You?

Under 18

18-39

40-59

60+

Do people say you always look tired? *

Yes

No

Do you feel that you have large bags under your eyes that won't go away? *

Yes

No

Do your eyelids always feel heavy? *

Yes

No

Do you try to open your eyes wider to see better? *

Yes

No

Do you think you feel younger than you look? *

Yes

No

What's Your Name?

First Name *

Last Name *

What Email Can We Contact You At?

Email: *

Phone Number: *

By submitting this form, I authorize Dougherty Laser Vision to send text messages, possibly using automated technology, to the number provided. Message/data rates apply.

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