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 *

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