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LATISSE® (bimatoprost ophthalmic solution) 0.03%
  • LATISSE® (bimatoprost ophthalmic solution) 0.03%
  • LATISSE® (bimatoprost ophthalmic solution) 0.03%
  • LATISSE® (bimatoprost ophthalmic solution) 0.03%
LATISSE® (bimatoprost ophthalmic solution) 0.03%
$199.00

Latisse Patient Consent Form

Thank you! Your medical questionnairehas been submitted successfully.
Please fill out all required fields.

1. Ocular History (Eyes)

Are you currently using any prescription eye drops for Glaucoma or ocular hypertension? (e.g., Lumigan, Xalatan, Timolol)
Have you ever been diagnosed with high eye pressure (Ocular Hypertension) or Glaucoma?
Have you had any eye surgery in the last 6 months (Cataract, LASIK, etc.)?
Do you have a history of eye inflammation (Uveitis or Iritis)?
Do you have any active eye infections or chronic "dry eye" symptoms?
Do you wear contact lenses? (Note: Lenses must be removed before application)

2. Medical History

Do you have any known allergies to Bimatoprost or other prostaglandins?
Are you currently pregnant, planning to become pregnant, or breastfeeding?
Do you have a history of skin sensitivity or eczema on your eyelids?

3. Informed Consent & Risks

Please initial next to each point to acknowledge you understand the potential side effects:

Permanent Pigmentation: I understand that Latisse may cause increased brown pigmentation of the colored part of the eye (the iris), which is likely permanent.
Skin Darkening: I understand that darkening of the eyelid skin may occur but is typically reversible if the product is discontinued.
Hair Growth: I understand that hair growth can occur in any skin area that Latisse frequently touches; I will blot any excess solution.
Common Irritation: I understand that eye redness, itchiness, and dryness are common side effects.

Patient Attestation

I certify that the information provided above is true and accurate to the best of my knowledge. I have been informed of the potential side effects and the proper application technique.

Details

For people with not enough lashes, LATISSE® grows fuller, darker, longer lashes at 16 weeks. Conduct a telemedicine visit with an Alora Med Spa physician to determine if LATISSE® is right for you. Incldues $25 telehealth visit fee on all orders.

LATISSE® (bimatoprost ophthalmic solution) 0.03% Important Information

LATISSE® (bimatoprost ophthalmic solution) 0.03% Important Information


Approved Use

LATISSE® is an FDA-approved treatment to grow eyelashes for people with inadequate or not enough lashes.

Important Safety Information

Do not use LATISSE® if you are allergic to one of its ingredients. If you use/used prescription products for eye pressure problems, use LATISSE® under doctor care. May cause brown darkening of the colored part of the eye which is likely permanent. LATISSE® may cause eyelid skin darkening which may be reversible. Only apply at base of upper lashes. DO NOT APPLY to lower lid. Hair may grow outside the treatment area. If you have eye problems/surgery, consult your doctor. Common side effects include itchy and red eyes. If discontinued, lashes gradually return to previous appearance.

These are not all the possible side effects of LATISSE®. For more information, please talk to your doctor.

Please see LATISSE® full Product Information.

 
Materials + Care

We prioritize quality in selecting the materials for our items, choosing premium fabrics and finishings that ensure durability, comfort, and timeless appeal.
Shipping + Returns

We strive to process and ship all orders in a timely manner, working diligently to ensure that your items are on their way to you as soon as possible.

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