StyeGuy Treatment Form

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Sorry - The Doctor is Not Available Today :(If you're here, we're sorry that you are having an eyelid problem. Our doctor is currently not available. Your best options are to call a local ophthalmologist, or call the emergency room and ask who the ophthalmologist on call is. Please do not submit a consultation. We hope you feel better soon!
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If you have an Eyelid Problem - We're Here to help!If you need an Antibiotic or Steroid, we are able to call it in directly to your pharmacy! We just need some information about your eyelid problem. There are 20 questions, it should take about 5 minutes to complete. And don't worry, your info is safe with us - we follow all HIPAA guidelines. The Doctor will get back to you within 2-4 hours (unless he is in surgery or asleep!)
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When did your Eyelid problem Start?* This field is required.
Within the past 24 Hours
Within the past 3 Days
About a Week ago
Within the past 1-4 Weeks
About 1-3 Months ago
More than 3 Months ago
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Since your problem started, it has ...* This field is required.
Improved
Gotten Worse
Stayed about the same
5
Is the whole EYELID red?* This field is required.
Yes
No
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Have you ever had something like this before?* This field is required.
Yes
No
7
Have you ever had, or do you get cold sores or fever blisters around your Mouth or Eyes?
Yes
No
8
It is normal to have a mild/moderate scratchy sensation when a stye rubs against your eye. But, do you have a severe, dull aching pain behind your eye when you look around?
I just have a mild scratchy sensation when I look around.
No, I have no significant pain/discomfort
Yes, I have a severe pain behind my eye when I look around.
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Do you have any light sensitivity?* This field is required.
Yes
No
10
Have you ever had bleeding from the bump?* This field is required.
Yes
No
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Do you feel like you have a fever, chills or muscle aches?* This field is required.
Yes
No
12
Cover the eye that does NOT have a stye. How would you describe the vision in your eye with a stye? The vision in my eye with a stye is:* This field is required.
Totally normal
A little blurred
Very blurry; I can't read well
Very bad/completely different than what I'm used to
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How painful is your eyelid?
No pain
Mild pain
Moderately painful
Very Severe Pain - Please help!
14
Have you used Warm Compresses?* This field is required.
Yes
No
15
How often did you do Warm Compresses? Was it Hot or warm?
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Have you used any Eye Drops or Ointments?* This field is required.
Yes
No
17
What are the name(s) of the medication(s)? For how many days and how many times per day have you been using the medication(s)?
18
Pharmacy Name & Address (example: CVS 10019 .. or .. CVS Anytown, NJ)Type in the name of your pharmacy and the town or zip code to get the address. If you don't have it, leave it blank.
Pharmacy Street Address
Pharmacy Street Address Line 2
Pharmacy City
Pharmacy State / Province
Pharmacy Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Past Eye History* This field is required.
List all your Past and Current Eye Problems
List any Surgeries or Lasers that you have had on your eyes
List any Eye Drops / Ointments you have used
20
General Medical Information* This field is required.
List all your Past & Current general medical conditions
List any medications you are ALLERGIC to - or write 'none' if you have no allergies to medications.
List of Medications (or type None)
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What is your main concern? List any questions you would like the doctor to answer. Also, please describe any other treatments that you have already tried.
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Upload a Picture(s) of your EyelidHaving problems? Just skip this and we'll contact you. Click "Browse Files" if you want to upload a 2nd or 3rd image. You can also email us the picture at info@StyeGuy.com or text it to (551) 800 - 7893.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Accepted file types: jpg, jpeg, png, gif, jpg, jpeg, png, gif.
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Demographic Info* This field is required.
First Name
Last Name
Cell Phone Number - We Will Text You
Email
Date of Birth - Month / Day / Year ** MUST BE OVER 10 YRS OLD **
Please Select
Please Select
Male
Female
Gender
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In case we need to call in an Antibiotic, we need to know if you pregnant, trying to get pregnant, or nursing?* This field is required.
Not Pregnant
Not Sure
Not Applicable
Trying to get Pregnant
Pregnant
Nursing
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Home Address* This field is required.
Street Address Line 1
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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