Beauty Redefined

Medical Aesthetic Clinic

408-356-7050

 

Patient Name: _______________________________________ Date: __________________

Indications – Prescription treatment for hypotrichosis used to grow eyelashes.

LATISSE SCREENING INTERVIEW

1. Do you use Lumigan or any other medication to treat intraocular pressure? ...........Y …..N

2. Are you pregnant or breastfeeding? ……………………………………………............Y …..N

3. Do you experience any of the following symptoms / conditions:

a. Eye pruritus (itchy eyes) ……………………………………………….............Y …..N

b. Conjunctival hyperemia (red eyes) ...............................................................Y …..N

c. Irritated eyes ..…………………….................................................................Y …..N

d. Dry eyes ..…...…………………….................................................................Y …..N

e. Eyelid redness …………………….................................................................Y …..N

f. Twitching eyelids ………………….................................................................Y …..N

g. Macular edema ..……...………….................................................................Y …..N

4. Do you have brown spots or discoloration of the eyelids? ........................................Y …..N

If you answered Yes to #1 or #2, you may not use Latisse.

If you answered Yes to any part of #3, we recommend you see your Opthamologist to correct and control your symptoms prior to starting Latisse.

If you answered Yes to #4, we recommend you see your Dermatologist before starting Latisse.

Latisse warnings, precautions and adverse reactions:

1. Do not use Latisse with other medications that lower Intraocular Pressure (IOP).

2. May cause permanent iris pigmentation if Latisse comes in continual contact with your eye.

3. Latisse may cause hyper pigmentation of the eyelid. This is reversible after stopping Latisse.

4. It is very important to apply Latisse to skin of upper eyelid margin at the base of the eyelashes to reduce the potential of unwanted hair growth outside treatment area.

5. Do not use Latisse if you have Macular edema.

6. Avoid contaminating Latisse applicators.

7. Do Not use if pregnant or breastfeeding.

8. Remove contact lenses prior to applying Latisse. Resume use of contact lenses 15 minutes after Latisse dries.

9. Red eye or conjunctal hyperemia will usually resolve in a few days to two (2) weeks. If it persists or suddenly worsens, discontinue Latisse.

10. Less than 4% of patients experience eye pruritus (itch), skin hyperpigmentation (darkening), ocular (eye) irritation, dry eye, Erythema (redness) of eyelids.

If these symptoms do not resolve in a few days, then discontinue Latisse and / or see your Ophthalmologist.

***Non-refundable – Latisse is a prescription drug - cannot be returned.****

 

Patient Signature:________________________________ Date: _______________________

 

Witness: __________________________________________________

Use as directed - see package insert.

LATISSE INFORMED CONSENT

 

 

I, ______________________________________________________, understand that I will be given a prescription for Latisse (bimatoprost ophthalmic solution) which is indicated to treat hypotrichosis (inadequate or not enough eyelashes) of the eyelashes by increasing their growth including length, thickness and darkness.

 

A. Contraindications

 

Hypersensitivity

  1. Patients with hypersensitivity to bimatoprost or any other ingredient in this product

 

Pregnancy

  1. While there are no adequate and well controlled studies for bimatoprost in pregnant woman Latisse should not be administered during pregnancy since the potential benefit does not justify the potential risk to the fetus
  2. Nursing mothers should not take Latisse since many drugs are excreted in human milk

 

Contact Lenses

  1. Latisse solution may be absorbed by soft contact lenses.  Contact lenses should be removed prior to application of solution and may be reinserted 20 – 30 minutes following its use.

 

 

B. The possible side effects of Latisse include but are not limited to:

 

1.      Risks:  I understand there is a risk of itching, increased blood in the eye, hyperpigmentation of the skin, irritation, dry eyes, redness, allergic reaction.

 

2.      Infection:   Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.

 

3.      Iris Pigmentation: Increased iris pigmentation has occurred.  You should be advised that the potential for increased brown iris pigmentation is likely to be permanent should this side effect occur.  Iris color changes may not be noticeable fore several months to years.

 

4.      Lid Pigmentation: Bimatoprost has been reported to cause pigment darkening of the eyelid.  This side effect has been reported to be reversible upon the discontinuation of treatment.

 

5.      Intraocular Inflammation:  Latisse solution should be used with caution in individuals with active intraocular inflammation (uveitis) because the inflammation may increase.

 

6.      Macular Edema:  Swelling of the small area of the retina responsible for central vision.  The edema is caused by fluid leaking from the retinal blood vessels.

 

C. Use

  1. Latisse must be used exactly as directed to reduce the risk of complications and side effects.
  2. The Latisse bottle must be kept intact during use.
  3. Place one drop on the single use per eye applicator.
  4. Bottle tip should never be allowed to contact any other surface to avoid contamination
  5. Sterile applicators may only be used on one eye and then discarded.  Reuse of applicators increases the potential for contamination and infections.
  6. Do not apply Latisse to bottom lashes
  7. Do not use Latisse more than once per day.  Additional application will not increase results but will increase the risk of possible complication and side effects.
  8. Upon discontinuation of Latisse eyelash growth is expected to return to its pre-use level
  9. Do not use Latisse on any other areas of the body.  Studies have not been performed as to the safety and effectiveness in any area other than the eyelashes

 

 

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.  I hereby release the doctor prescribing Latisse and the facility from liability associated with this procedure.

 

 

 

Patient Signature______________________________________Date:___ _____