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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