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ACTIVATING LIPOSOME COMPLEX
  • ACTIVATING LIPOSOME COMPLEX
ACTIVATING LIPOSOME COMPLEX
$79.00

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

SKIN TYPES/CONDITIONS: Red or Yellow-Toned, Dehydrated, Combination or Confused, Exposed to High Levels of Radiation, Sensitive, Uneven, Rough-Textured, Stressed, Laser/Chemically-Treated or Other Post-Procedure, Sun-Damaged, Finely Lined or Deeply Wrinkled, Blemished or Acne-Prone, Immuno-Compromised

ACTIVE INGREDIENTS: Beta Glucan • Superoxide Dismutase • Silver Ear Mushroom • Trehalose • Sodium Hyaluronate • Phospholipids

This Complex has multiple uses for every type of skin. It diminishes visible imperfections within days to weeks and normalizes red or yellow skin tones within 2 to 4 weeks. It will also speed up the skin’s recovery from any procedures such as laser treatment or re-surfacing. Helps clear breakouts within 48 hours and reduces signs of ongoing sensitivity.

HOME CARE: Apply 1 to 3 pumps of Complex to a freshly cleansed face and neck twice a day. This may also be applied wherever the healthy appearance of external skin is compromised.
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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