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PORE PURIFYING ASTRINGENT
  • PORE PURIFYING ASTRINGENT
  • PORE PURIFYING ASTRINGENT
PORE PURIFYING ASTRINGENT
$38.00

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

Refreshing, exfoliating astringent helps correct visible imperfections without drying skin.

Actions

  • Pore-purifying essential oils balance pore ecology
  • Helps visibly clear imperfections without drying skin
  • AHA/BHA blend minimizes pores
  • Counteracts visible signs of redness

Skin Conditions

Mild to Severe Acne-Prone | Congested

Action Ingredients

Betaine Salicylate | natural skin conditioner from sugar beets complexed with keratolytic BHA; provides time-released exfoliating action long after cleanser is rinsed away
4-Terpineol | highly purified active fraction of Australia Tea Tree oil; delivers broad-spectrum inhibition of hostile skin flora without irritation or allergens associated with pure Tea Tree Oil
Leptospermum Scoparium Oil | New Zealand Tea Tree Oil; delivers broad-spectrum inhibition of hostile skin flora without irritation or allergens associated with pure Tea Tree Oil
Sugar Cane, Citrus & Apple | natural AHA blend gently works to dissolve sebum in clogged pores
Green Tea | soothes signs of redness, calms discomfort
Dipotassium Glycyrrhizate | soothing molecule from licorice calms on contact

Ingredient List

water (base), alcohol denat. (BHA solvent), betaine salicylate (exfoliating BHA), glycerin (hydrating), decyl glucoside (softening), polysorbate 20 (emulsifier), 4-terpineol (pore purifying), dipotassium glycyrrhizate (soothing), camellia oleifera leaf extract (soothing), camellia sinensis leaf extract (soothing), leptospermum scoparium branch/leaf oil (pore purifying essential oil), malic acid (exfoliating AHA), acer saccharum (sugar maple) extract (exfoliating), lavandula angustifolia (lavender) extract (pore purifying extract), saccharum officinarum (sugarcane) extract (exfoliating AHA), vaccinium myrtillus fruit extract (exfoliating), butylene glycol (hydrating), aminomethyl propanol (pH adjustor), citric acid (pH adjustor), tetrasodium glutamate diacetate (chelating agent), sodium benzoate (antimicrobial preservative), citrus aurantium dulcis (orange) fruit extract (exfoliating AHA), citrus limon (lemon) fruit extract (exfoliating AHA), eucalyptus globulus leaf oil (pore purifying essential oil), melaleuca alternifolia (tea tree) leaf oil (pore-purifying 4-terpineol), salvia officinalis (sage) oil (pore purifying essential oil), thymus vulgaris (thyme) oil (pore purifying essential oil). 

 

 

 

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