NewSkinLaserCenter.com

Latisse Form

Please fill this form in order for your product to be shipped. 

All of the fields are required.  If not applicable, just state "NONE".

 

With respect to Latisse®, my typed name bellow is equivalent to my signature and is a my consent for you to treat me as one of your patients. My electronic signature is also proof to you that I understand and feel informed about the product, and agree to the online ordering option.

I have reviewed all of the information provided on the Medical Consent Form, the FAQ's & Latisse Information Page, and feel fully informed about the product. (If you have not already done so - please review now, before proceeding any further.)

I certify that all of the information provided by me here is true and correct, and if approved, agree to use Latisse as intended and directed.

No, I am NOT currently pregnant, breast feeding, or planning on getting pregnant while using Latisse. (Effects are unknown in the clinical study.)

I do not have Glaucoma, or allergies to eye drops or bimatoprost opthalmic solution.

 

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