Patient Identification

Full Legal Name (Must match your Photo ID) *

Date of Birth *

Address

Street Address

City

Province

Country

Postal Code

Email *

Phone *

Primary Eye Health Screen

Medical History: Have you ever been diagnosed with any of the following?GlaucomaIncreased Intraocular Pressure (IOP)Macular EdemaIritis or Uveitis (Eye Inflammation) *

Yes

No

Current Eye Medications: Are you currently using any eye drops or medications for eye pressure (e.g., for Glaucoma or Ocular Hypertension)? *

Yes

No

Recent Procedures: Have you had any eye surgeries or laser procedures in the last 6 months? *

Yes

No

General Health & Allergies

Pregnancy/Nursing: Are you currently pregnant, planning to become pregnant, or breastfeeding? *

Yes

No

Allergies: Do you have a known allergy to Bimatoprost or the preservative Benzalkonium Chloride? *

Yes

No

Contact Lenses: Do you wear contact lenses? *

Yes

No

Informed Consent (Checkboxes)

*

I understand that Latisse is a prescription medication and will only be dispensed if deemed appropriate by a healthcare provider.

I have been informed of potential side effects, including eye redness, skin darkening of the eyelid, or rare changes in iris pigmentation.

I agree to apply the product only to the base of the upper eyelashes as directed.

I understand that if I am not a candidate for Latisse, my order will be fully refunded.

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