Medical History Requirement (required to order Latisse online) Personal Information (all fields are required) Name Date of Birth (you must be 18+ years old to order Latisse, so you must have been born on or before May 28, 2005 to continue): Address City State (we can ship to the 48 contiguous states): Zip Phone Email Medical Information & Consent (all fields are required) Yes, I have reviewed all the information on the Patient Information page. Medication Allergies Eye Medications Eye Conditions/Surgeries Glaucoma patients: please note! In some cases, Latisse can still be used safely if you've been diagnosed with IOP or Glaucoma; however, if you are currently being treated for this condition, you can't order Latisse online until we have medical clearance from your eye physician. Are you currently pregnant, trying to get pregnant, or breast feeding? If so, DO NOT CONTINUE . Women in this category were not included in clinical trials, and therefore Latisse's effect is unknown at this time: Yes No Release of Liability (must be checked to proceed): Yes, I accept full responsibility for any and all adverse side effects that may occur if I choose to use Latisse. I hereby release Allergan, Ultra Smooth Skin, Lisa Williams and staff of any and all liability in connection with the use of Latisse. Consent to treat (must be checked to proceed): Yes, with respect to Latisse, I waive my option to be seen in person and agree to use Latisse as intended and directed. My electronic signature below is my consent for you to treat me as one of your patients. I understand and feel informed about the product and agree to the online ordering option. Electronic Signature 7 + 30 - 10 =
