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Active Plant-Based Wellness Patch
  • Active Plant-Based Wellness Patch
  • Active Plant-Based Wellness Patch
  • Active Plant-Based Wellness Patch
  • Active Plant-Based Wellness Patch
Active Plant-Based Wellness Patch
$12.00

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

A plant-powered wearable wellness patch to get you moving. Infused with Caffeine, Beta Alanine, L-Citrulline, and Rhodiola. This 4-way stretch fabric is perfect for that early morning workout, after-work gym sesh, or when you need a new workout buddy (but don’t want to hear about their fitness goals).                                  

- EASY TO USE: Simply peel, stick on your wrist or any venous area, and feel. 
- ALL DAY WELLNESS: Sustained release of ingredients up to 8-12 hours. 
- YOU'RE IN CONTROL: On when you need it, off when you don't.
- CONVENIENT: Perfect for life on-the-go 
- 4-WAY STRETCH FABRIC: To withstand your toughest workout
- RESPONSIBLY MADE: Vegan, cruelty free, made without latex, paraben free, dermatologically tested, and made in the USA with global ingredients

 

Product details

• Made in United States
• Ingredients: Caffeine, Beta Alanine, L-Citrulline, Rhodiola Extract (Rhodiola Rosea), Adhesive
Crafted with 25mg caffeine per patch                                
• Product Language: English
• Weight: 0.2 oz (5.67 g)
• Dimensions: 0.2 x 3.5 x 6 in (0.5 x 8.9 x 15.2 cm)

Eco-friendly information

Product Materials: Vegan

Production: Cruelty-free
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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