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