Please fill this form in order for us to ship your Latisse. This form should be submitted at the same time of placing your order.
Write None or N/A if it does not apply to you.
Name*:
Email Address*:
Phone Number*:
Medical History*:
List Your Medications:
Allergies*:
Eye Conditions and Surgeries:
Release Of Liabilities:
With respect to Latisse®, my typed name above is equivalent to my signature and is a my consent for you to treat me as one of your patients. My electronic signature is also proof to you that I understand and feel informed about the product, and agree to the online ordering option.
I have reviewed all of the information provided on the Medical Consent Form, the FAQ's & Latisse Information Page, and feel fully informed about the product. (If you have not already done so - please review now, before proceeding any further.)
I certify that all of the information provided by me here is true and correct, and if approved, agree to use Latisse as intended and directed.
No, I am NOT currently pregnant, breast feeding, or planning on getting pregnant while using Latisse. (Effects are unknown in the clinical study.)
I have read and agree to the Privacy Policy.
No, I am NOT currently pregnant, breast feeding, or planning on getting pregnant while using Latisse. (Effects are unknown in the clinical study.)
I do not have Glaucoma, or allergies to eye drops or bimatoprost opthalmic solution
* I accept full responsibility for any and all adverse side effects that may occur if I choose to use Latisse®. I hereby release Allergan, NewSkin Laser Center, and Dr. Alan Darush of any and all liability in connection with using this product.

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