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Intensive Eye Therapy Creme
  • Intensive Eye Therapy Creme
  • Intensive Eye Therapy Creme
Intensive Eye Therapy Creme
$49.00

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

Ultra-retexturizing creme that relaxes and fills lines from within, signaling cells to act younger and delivering dramatic results in hours to days.

Actions

  • Fills lines from within
  • Visibly relaxes tension lines and wrinkles
  • Signals cells to act younger – so skin looks younger
  • Neutralizes aging surface radicals

Skin Conditions

All Skin Types | Lined | Mature | Wrinkled | Aging | Dehydrated

Home Care

Briskly run the tips of your little fingers together to warm a small amount of creme, then apply three tiny dots of creme around each eye. Gently blend.

Action Ingredients

SNAP-8™ | patented octapeptide visibly relaxes lines, wrinkles and furrows due to microtension around eyes
Sodium Hyaluronate | ‘self-injecting’ spheres of dehydrated hyaluronic acid “lift” lines around eyes
Shea Butter | emollient “butter” from the karite tree; softens skin and promotes natural repair
Astaxanthin | most powerful of the carotenoid antioxidant family; helps protect cells from free radical damage and lipid peroxidation
Dermaxyl™ | olipeptide/ceramide complex enhances firmness while creating softer, more supple skin

Action Ingredients

water (base), butyrospermum parkii (shea) butter (softening), cetyl ethylhexanoate (emollient emulsifier), dimethicone (breathable silicone), cetearyl alcohol (emollient), cetyl esters (emollient), bis-diglyceryl polyacyladipate-2 (skin softener), glycerin (hydrating), ethylhexyl palmitate (softening), C12-15 alkyl benzoate (emollient), phytosteryl isostearate (emollient), acetyl octapeptide-3 (SNAP-8), ceramide NG (barrier lipid), haematococcus pluvialis extract (soothing antioxidant), palmitoyl hexapeptide-12 (firming peptide), sodium hyaluronate (hydrating), astaxanthin (soothing antioxidant), tocopherol (freshness preservative), helianthus annuus (sunflower) seed oil (lipid-rich moisturizer), squalane (moisturizing lipid), ethylhexylglycerin (skin conditioner), cetearyl glucoside (emulsifier), polyglyceryl-10 laurate (skin-softening emulsifier), behenyl alcohol (emollient), tribehenin (thickener), ceteareth-20 (mild emulsifier), laureth-4 (emulsifier), PEG-10 phytosterol (emulsifier), polysorbate 60 (mild emulsifier), polysorbate 80 (mild emulsifier), amorphophallus konjac root powder (natural viscosity modifier), hydroxyethyl acrylate/sodium acryloyldimethyl taurate copolymer (emulsion stabilizer), trihydroxystearin (skin conditioning), xanthan gum (slip agent), disodium EDTA (mineral chelator), methylpropanediol (antimicrobial preservative), tromethamine (pH adjuster), caprylhydroxamic acid (antimicrobial preservative). 

 
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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