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In order to buy this product, please answer each question. Additionally, you must register at checkout and provide your telephone number. We will call you to verify your order.

 
1. Please list medical conditions you have, if any?
 
2. Medications (please list)
 
3. Allergies (please list)
 
4. If you are pregnant, nursing, or taking fertility drugs, please specify below?
 
5. Other
 
6. Your typed name below is equivalent to your legal signature.
 
7. Hypersensitivity to Latisse/Lumigan/bimatoprost *
No
Yes
8. Ocular inflammation *
No
Yes
9. Glaucoma *
No
Yes
10. Aphakia *
No
Yes
11. Macular edema *
No
Yes
12. Increased intraocular pressure *
No
Yes
13. Signature Verification *
No, I have not signed.
Yes, I have signed.