Informed Consent

In order to purchase Latisse on YourLaserSkinCare.com, you must fill out the requested information below, as well as read and sign the Informed Consent form below. YourLaserSkinCare.com is an authorized Allergan Latisse Representative, which ensures your safety.

Basic Information

Name

DOB (mm/dd/yyyy)

Phone

GenderMaleFemale

I have used Latisse in the pastYesNo

Medical History

What medical conditions do you have, if any?

What medications are you currently taking, if any?

Please list the drug allergies that you have, if any?

If you are pregnant, nursing, or taking fertility drugs, please specify below.

If you have any other medical condition or information that we need to know, please specify below.

Informed Consent

I request and consent that I will receive Latisse (bimatoprost ophthalmic solution) which is a prescription product, FDA approved to treat hypotrichosis (inadequate or not enough eyelashes). I agree that I am, and will be under the care of another medical provider for all other conditions. YourLaserSkinCare.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 YourLaserSkinCare.com only prescribe Latisse for the treatment of lengthening, thickening, and darkening eyelashes. YourLaserSkinCare.com does not accept or bill insurance for this program.

Contraindications

Hypersensitivity

Latisse is contraindicated in patients with hypersensitivity to bimatoprost or any other ingredient in this product.

Pregnancy

I understand that use of Latisse is absolutely contraindicated during pregnancy and breastfeeding
While there are no adequate and well controlled studies for bimatoprost ophthalmic solution 0.03% administration in pregnant and/or nursing women,
Latisse should not be administered during pregnancy since the potential benefit does not justify the potential risk to the fetus.
Nursing mothers should not take Latisse since many drugs are excreted in human milk.
I understand that it is my responsibility to inform YourLaserSkinCare.com if I am pregnant, could become pregnant, or should become pregnant during the course of the treatments.

Contact Lenses

Latisse solution may be absorbed by soft contact lenses. Contact lenses should be removed prior to application of solution and may be reinserted 20-30 minutes following its use.

I understand that there are associated risks and unintended side effects while using Latisse as there are with all other medications. These possible side effects of Latisse include but are not limited to:

Risks: I understand there is a risk of itching, increased blood in the eye, hyperpigmentation of the skin, irritation, conjunctival hyperemia (redness of eyes), itchy eyes, dry eyes, redness, allergic reaction, visual disturbances, and eye pruritus.
Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.
Iris Pigmentation: Increased iris pigmentation has occurred. You should be advised that the potential for increased brown iris pigmentation is likely to be permanent should this side effect occur. Iris color changes may not be noticeable for several months to a year.
Lid Pigmentation: Bimatoprost has been reported to cause pigment darkening of the eyelid. This side effect has been reported to be reversible upon the discontinuation of the treatment.
Intraocular Inflammation: Latisse solution should be used with caution in individuals with active intraocular inflammation (uveitis) because the inflammation may increase. If you are using LUMIGAN* ophthalmic solution or other products for elevated intraocular pressure (IOP), or if you have a history of abnormal IOP, you should only use Latisse under the close supervision of you physician.
Macular Edema: Swelling of the small area of the retina responsible for central vision. The edema is caused by fluid leaking from the retinal blood vessels.

I understand that if any of the above side effects occur I should discontinue Latisse use immediately and agree to immediately consult with my medical provider.

I understand Latisse must be used exactly as directed to reduce the risk of complications and side effects and that any misuse of Latisse could increases the chances of unintended side effects.

The Latisse bottle must be kept intact during use.
Place one drop on the single use per eye applicator.
Bottle tip should never be allowed to contact any other surface to avoid contamination.
Sterile applicators may only be used on one eye and then discarded. Reuse of applicators increases the potential for contamination and infection.
Latisse should only be applied to the skin of the upper eyelid margins at the base of the eyelashes. Do not apply Latisse to bottom lashes.
Do not use Latisse more than once per day. Additional application will not increase results but will increase the risk of possible complications and side effects.
Upon discontinuation of Latisse eyelash growth is expected to return to its pre-use level.
Do not use Latisse on any other areas of the body. Studies have not been performed as to the safety and effectiveness in any area other than the eyelashes.
It is possible for hair growth to occur in other areas of your skin that Latisse frequently touches. Any excess solutions outside the upper eyelid margin should be blotted with a tissue or other absorbent material to reduce the chance of this happening.
It is possible for a difference in eyelash length, thickness, fullness, pigmentation (darkness), number of eyelash hairs and/or direction of eyelash growth to occur between eyes (e.g., results may vary for each eye). These differences, should they occur, will usually go away if you stop using Latisse.

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

By signing below, I acknowledge that I have read the foregoing informed consent and fully understand the terms within the above consent. I agree to the treatment of Latisse with its associated risks. I accept full responsibility for any and all adverse side effects that may occur while using Latisse®. I hereby release the doctor prescribing Latisse and Your Laser Skin Care of any and all Liability associated with using this product. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.

Your typed name at the bottom of the form is equivalent to your signature.

Digital Signature

Date (mm/dd/yyyy)