LatisseTM Consent Form

LatisseTM Consent Form

LatisseTM is FDA-approved for the treatment of the eyelashes by making them grow longer, thicker, and darker. The onset of action is gradual with most users seeing a significant improvement in the length and number of lashes by two months. If LatisseTM is discontinued the lashes and eyelids will return to their previous appearance over several weeks to months.
Please review and sign this consent form and remit payment for Latisse to be shipped to you, prescribed by Dr. Lily Talakoub.
Patient Name *

First Name Middle Name Last Name
Sex
Date of Birth *

Month Day Year
Email *
example@example.com
Phone Number *

Area Code Phone Number
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Risks and Possible Side Effects of Using LatisseTM

Please review and select each bullet below to indicate that you understand the risks and possible side effects of using LatisseTM, have been given the opportunity to speak with a healthcare provider about this in more detail and have any questions answered.
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Eye itching and irritation
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Conjunctival hyperemia or red eye (redness of the white, moist covering of the eyeball)
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Dry eye symptoms
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Eyelid redness
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Although rare, LatisseTM has the potential to permanently increase the brown pigmentation of the iris (the colored part of the eyeball, inside the eye)
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LatisseTM may cause darkening of the eyelid skin which may or may note be reversible upon discontinuation of treatment.
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LatisseTM may lower intraocular pressure (IOP) or pressure inside the eye.
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If you have a history of abnormal eye pressures or glaucoma you should only use LatisseTM under the close supervision of your opthalmologist.
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You should inform anyone conducting eye pressure examinations that you are using LatisseTM.
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Do not use LatisseTM if you are allergic or hypersensitive to bimatoprost (Lumigan) or any other ingredient in this product.
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Do not apply LatisseTM to the lower lids as this will increase the chance of darkening of the eyelid skin.
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You should discontinue use of LatisseTM and call your physician immediately if you develop an eye infection, sudden decrease in vision, suffer eye trauma, or develop eye or eyelid reactions.
Contraindications of using LatisseTM

You should not use LatisseTM if any of the following apply to you:
- You are allergic or hypersensitive to bimatoprost (Lumigan) or any other ingredients in this product
- You are about to undergo cataract or other eye procedures
- You have intraocular inflammation (uveitis)
- You have risk factors for macular edema
- You have an eye infection
- You are being treated for glaucoma with eye drops, unless cleared by your treating opthalmologist
- You are under the age of 18
- You are pregnant or lactating
Patient's Acceptance of Risks

Please read and select each of the following options to indicate that you have read, understand, and have been given the opportunity to discuss this product and its intended treatment with a healthcare professional in order to answer any questions you may have.
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I have read the above information and have been given the opportunity to schedule an appointment with a physician or other healthcare provider to discuss this at length
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I understand that it is impossible for the physician to inform me of every possible complication that may occur.
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I understand that use of this medication is cosmetic, elective, and optional.
Signature *

Clear
Date Signed *

Month Day Year
Date
My Products *
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Latisse 5mL $ 180.00
LATISSE® (bimatoprost ophthalmic solution) 0.03% — the first FDA-approved treatment for inadequate or not enough lashes.

Subtotal $ 0.00 Tax $ 0.00 Shipping $ 0.00 Total $ 0.00
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LatisseTM Consent Form

Risks and Possible Side Effects of Using LatisseTM

Contraindications of using LatisseTM

Patient's Acceptance of Risks