Patient Identification
Full Legal Name (Must match your Photo ID)
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Date of Birth
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Address
Street Address
City
Province
Country
Country
Postal Code
Email
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Phone
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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)
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Yes
No
Current Eye Medications: Are you currently using any eye drops or medications for eye pressure (e.g., for Glaucoma or Ocular Hypertension)?
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Yes
No
Recent Procedures: Have you had any eye surgeries or laser procedures in the last 6 months?
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Yes
No
General Health & Allergies
Pregnancy/Nursing: Are you currently pregnant, planning to become pregnant, or breastfeeding?
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Yes
No
Allergies: Do you have a known allergy to Bimatoprost or the preservative Benzalkonium Chloride?
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Yes
No
Contact Lenses: Do you wear contact lenses?
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Yes
No
Informed Consent (Checkboxes)
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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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