LatisseTM Consent Form

Latisse™ Consent Form
Latisse™ 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 significant improvement in the length and number of lashes by 2 months.

If Latisse™ is discontinued the eyelashes and eyelids will return to their previous appearance over several weeks to months.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Unit / Apartment Number

CityState / Province

Postal / Zip Code
Sex*

FemaleMale
I am not pregnant, planning a pregnancy or nursing*

YesNo
Date of Birth*

MonthDayYear
Email*
example@example.com
Phone Number*
I would like to receive SMS notifications such as prescription expiration reminders, offers and treatments, updates from your healthcare provider, shipping and order updates.*

Yes, I would like to receive SMS notifcations.No, thanks.
Have you used LatisseTM before?*
Risks and Possible Side Effects of Using Latisse™

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

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.
I agree to the terms, privacy policy and consent for telehealth
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
I understand that it is impossible for the physician to inform me of every possible complication that may occur.
I understand that use of this medication is cosmetic, elective, and optional.
I have been informed that results are not guaranteed.
By signing below, I agree that all of questions have been answered by a healthcare professional and I give informed consent to proceed with Latisse™ treatment. *

Clear
Date Signed*

MonthDayYear
Date
Patient Shipping Address*

Street Address

Unit / Apartment Number

CityState / Province

Postal / Zip CodeCountry
My Products*
prevnext( X )
Latisse 5mLLATISSE® (bimatoprost ophthalmic solution) 0.03% — the first FDA-approved treatment for inadequate or not enough lashes.
$190.00 Quantity

Subtotal

$0.00

Tax

$0.00

Shipping

$0.00

Total

$0.00
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Latisse™ Consent Form

Risks and Possible Side Effects of Using Latisse™

Contraindications of using Latisse™

Patient's Acceptance of Risks