Latisse Consent

I request Latisse® eyelash enhancer for the purpose of lengthening, thickening, and darkening my eyelashes. I understand that as part of the program I will be given the Latisse® formula with supporting materials and will be instructed on how to administer the drops myself. In published studies, 80% will respond to treatment after eight to sixteen weeks.

I understand Latisse® is FDA approved for lengthening, thickening, and darkening of the eyelashes. I understand Dr. Tkatch  or her designates prescribe Latisse® for the treatment of lengthening, thickening, and darkening of eyelashes.

Prior to my treatment, I have fully disclosed any medical conditions or diseases such as: pregnancy, breastfeeding, history of glaucoma, aphakia (absence of lens in the eye), macular edema, ocular inflammation, hypersensitivity to Latisse ® (or bimatoprost), or other serious medical conditions.

While Latisse® is mostly free of negative side effects, with any medication there is the possibility of an allergic reaction or unusual reactions. Latisse® may cause conjunctival hyperemia (redness of eyes), itchy eyes, dry eyes, visual disturbances, ocular blurring, foreign body sensation, reversible periorbital skin darkening, blepharitis (inflammation of the eyelids), keratitis (inflammation of the cornea), eyelid erythema, ocular irritation, permanent iris discolouration, or photophobia (sensitivity to light). I understand that potential unknown risks may exist.

I will immediately report any problems that might occur to MD Wellness Solutions during the treatment. I further understand that not complying with the dosage recommendations and application instructions could alter my results. It is necessary to use Latisse® on an ongoing basis to maintain results.

I understand that Latisse should not be used if I have a history of Ocular inflammation, Glaucoma, Aphakia, Mascular edema, Increased intraocular pressure, or Heart disease? 

I understand that Latisse® should not be used during pregnancy and breastfeeding. I understand that it is my responsibility to inform MD Wellness Solutions if I am pregnant, could be pregnant, or should become pregnant during the course of the treatments.

I am over the age of 19 years old.

I will inform MD Wellness Solutions  of any changes in my medical history and current medications prior to any future treatments.

I have read and fully understand the terms within the Latisse® Informed Consent.

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