Latisse Consent Form

Latisse Intake and Consent Form
Latisse Intake and Consent Form
First Name *
Last Name *
Date of Birth *

MM 		/
DD 		/
YYYY
Gender *
 Male 
 Female 

MEDICAL HISTORY
What medical conditions do you have, if any?
What medications are you currently taking, if any?
Please list the drug allergies you have, if any.
Are you pregnant, nursing, or taking fertility drugs?
 No 
 Yes 
If you have any other medical condition or information that we need to know, please specify.

Medical Conditions

Have you ever been diagnosed with the following conditions:
Hypersensitivity to Latisse / Lumigan / Bimatoprost
 No 
 Yes 
Ocular inflammation
 No 
 Yes 
Glaucoma
 No 
 Yes 
Aphakia
 No 
 Yes 
Macular edema
 No 
 Yes 
Increased intraocular pressure
 No 
 Yes 

Informed Consent

I request and consent to receive Latisse eyelash enhancer for the purpose of lengthening, thickening, and darkening my eyelashes. I understand that as part of the program I will be given the Latisse formula with supporting materials and will be instructed on how to administer the drops myself. I understand that this initial intake form will be necessary to rule out any conditions that would disqualify me from the program. I will obtain this form from DrLinDirect.com

I understand Latisse is FDA approved for lengthening, thickening, and darkening of the eyelashes. I agree that I am, and will be under the care of another medical provider for all other conditions. DrLinDirect.com can work in conjunction with, but cannot replace, regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand the physicians with DrLinDirect.com only prescribe Latisse for the treatment of lengthening, thickening, and darkening eyelashes. DrLinDirect.com does not accept or bill insurance for this program.

Prior to my treatment, I have fully disclosed any medical conditions or diseases such as: pregnancy, breastfeeding, history of glaucoma, aphakia (absence of lens in the eye), macular edema, ocular inflammation, hypersensitivity to Latisse (or bimatoprost), or other serious medical condition. Any contraindications for the use of Latisse have been fully disclosed to me.

I understand that use of Latisse is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform DrLinDirect.com if I am pregnant, could be pregnant, or should become pregnant during the course of the treatments.

While Latisse is mostly free of negative side effects with any medication there is the possibility of an allergic reaction or unusual reactions that may cause conjunctival hyperemia (redness of eyes), itchy eyes, dry eyes, visual disturbances, ocular blurring, foreign body sensation, periorbital skin darkening, blepharitis, keratitis, eyelid erythema, ocular irritation, iris discoloration, or photophobia. I understand that the medications may involve risk.

I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that there are risks involved as there are with all medications and that not complying with the dosage recommendations could increase risks and alter my results from the program. I understand that I may quit the program at any time. No adverse side effects or complications are expected, but in the event that an illness does occur, I understand that I need to contact DrLinDirect.com. If I experience an emergency situation, I understand that I need to go to an emergency facility.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this treatment. I will also inform DrLinDirect.com of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.

Your typed name below is equivalent to your signature
Electronic Signature (First and Last Name) *
Email *
Phone Number

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