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

MonthDayYear
Full Name

First NameMiddle NameLast Name
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please check each box to acknowledge
Birth Date

MonthDayYear
E-mail
Phone Number
Format: (000) 000-0000.
This is my:
Signature

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