Ptosis Crutch Request

Tell us how to reach you and a little about the frame. Every field marked * is required. We respond within two office days.

Prefer paper? You can still download the intake form (PDF) to bring to an in-person visit.

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Patient

First name *

Surname *

Date of birth *

Day, month, and year — for example 07 / 03 / 1958.

Day Month Year

Phone *

Include your country code if you are outside the US.

Email *

Mailing address

Street address *

Street address line 2 (optional)

City / Town *

Region / State / Province *

Postal / ZIP code *

Country *

Alternate contact (optional)

The patient cannot communicate for themselves — add someone we can contact.

Frame

How is the frame being provided? *

* Zyl, plastic, and acetate frames can only be fitted locally after an in-person visit.

These are optional. If you have the frame in hand, they help us plan — but you can leave them blank and we will confirm at fitting.

Brand (optional)

Model (optional)

Metal type (optional)

Frame size (optional)

The boxing numbers, in the order eye – bridge – temple. Format xx-xx-xxx or xx-xx — for example 53-15-145 or 52-17. Temple length is optional. The diagram below shows where to find them.

Eye Bridge Temple (optional)

The three numbers are usually stamped inside one temple arm, and sometimes on the bridge.

Before you submit

I understand that frame paint will be scorched during soldering. I understand that ptosis crutches can worsen dry eye symptoms due to increased exposure, and that results for blepharospasm can be mixed. *

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Prefer to call? 732-615-9300