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Calm Mood Lavender Chamomile
  • Calm Mood Lavender Chamomile
  • Calm Mood Lavender Chamomile
  • Calm Mood Lavender Chamomile
  • Calm Mood Lavender Chamomile
Calm Mood Lavender Chamomile
$24.00

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

Functional Herbal Hard Candies and Lozenges made with pure botanicals, herbs, minerals, natural flavors and natural colors. 

Hydrate your throat and mouth and soothe your mind! Savor the calming and soothing combination of Ashwangandha and California poppy blended with pure Lavender Oil to create a smooth, luscious and mouthwatering Functional Herbal Lozenge.

Lavender Chamomile Natural Flavor

14 Lozenges per 2.22 oz Pouch
Vegan
Gluten Free
Non-GMO
Sugar Free - Made with Isomalt
Made in the USA
Made in small batches in a nut-free facility 

Ingredients: Isomalt, Water, Organic Stevia, Natural Lavender-Chamomile Flavor, Sunflower Oil, Citric Acid, Magnesium Glycinate, Lavender Oil, Ashwagandha, Valerian Extract, California Poppy Extract, Natural Color (Purple Sweet Potato)

Product details

• Made in United States

Eco-friendly information

Product Materials: Plastic-free

Production: Cruelty-free and Ethically sourced
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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