Latisse Intake and Consent Form

Latisse Consent Form

Latisse is a prescription item and informed consent must be obtained before order can be completed.
Date *

Month Day Year
Full Name *

First Name Middle Name Last Name
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Please check each box to acknowledge
Birth Date

Month Day Year
E-mail *
Phone Number *
This is my: *
Signature *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
Should be Empty: