Latisse Eye Evaluation Consent Form
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Date of last eye exam
-
Month
-
Day
Year
Date
1. Have you ever been told you have glaucoma or increased pressure inside your eye?
No
Yes
2. Does anyone in your immediate family have glaucoma or increased pressure?
No
Yes
3. Are you presently taking or have taken any glaucoma medication? If so, please list them:
I have not
I have
4. At your last examination were you told that you have problems with your eyes? If so, please explain:
No
Yes
5. Do you require glasses or contact lenses?
No
Yes
6. Have you had any injuries or surgery to the eye or lids? Explain:
No
Yes
7. Are you bothered by frequent irritations or allergies of the eyes or lids? Explain:
No
Yes
8. Are you sensitive to any of the following products:
Benzalkonium Chloride
Sodium Chloride
Sodium Phosphate Dibasic
Citric Acid
None of the above
9. Do you feel your eyes of lids swell excessively or become irritated easily?
No
Yes
10. Do you take or have ever taken medications or drops for the eyes for any reason? Explain:
No
Yes
11. Do your eyes water or tear spontaneously (without emotional stimulation)?
No
Yes
12. Do you now or have you ever had any visual problems with one or both eyes? Explain.
No
Yes
13. Are there any problems with your eyes not otherwise mentioned? Explain.
No
Yes
14. Are you pregnant or breastfeeding?
No
Yes
15. Do you have any health issues not related to your eyes? Explain.
No
Yes
16. Do you take any medications, non-prescription or herbal supplements? Explain.
No
Yes
17. Do you have any allergies? If yes, please list
I hereby acknowledge that I have fully disclosed, to the best of my knowledge, my compete medical history and have answered all the questions as completely as possible. Claudia Toubiah, NP & Rochele Carpio, RN is not responsible for any adverse events that occur because of failure to disclose health information as requested.
Submit
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