Your doctor-review questionnaire.

Thank you — your payment went through. This 2-minute form is your telehealth visit: a Cohenmehr Optometry doctor reviews it within 1 business day, then your Upneeq ships. If the doctor finds you're not a candidate, your payment is refunded in full.

Reordered within the last 12 months? You're done — no form needed. We match your order to your chart.

Your eyes

Which eyelid droops? How long has it been droopy?

Does the lid ever block part of your vision (driving, reading, TV)?

YesNo

Have you used Upneeq before?

YesNo

Have you been told you have narrow angles or narrow-angle glaucoma?

YesNo

Any eye surgery, eye injury, or eye infection in the last 6 months?

YesNo

Do you wear contact lenses?

YesNo

Significant dry eye or eye irritation currently?

YesNo

Your health

Heart disease, irregular heartbeat, or a history of stroke?

YesNo

High or low blood pressure that is NOT well controlled?

YesNo

Do you ever feel faint or dizzy when standing up (orthostatic hypotension)?

YesNo

Are you taking an MAO inhibitor (e.g. selegiline, phenelzine, tranylcypromine)?

YesNo

Pregnant or breastfeeding?

YesNo

Do you use any other prescription eye drops?

YesNo

Medications you take (or “none”)

Anything else the doctor should know? (optional)

Consent to telehealth. I consent to a telehealth evaluation by a Cohenmehr Optometry doctor based on my answers above, and I confirm my answers are accurate and complete.Doctor review before shipping. I understand my order ships only after a doctor approves it, and that if I am not a candidate my payment will be refunded in full.Photo follow-up if needed. If the doctor needs a photo of my eyes to complete the review, I will reply to the confirmation email with one.

Prefer to talk it through? Call 310-828-2010 — we're happy to do this over the phone.

Your doctor-review questionnaire.

About you

Your eyes

Your health