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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


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


  1. While there are no adequate and well-controlled studies for bimatoprost in pregnant women 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, and allergic reaction.

  2. Infection: Infections can occur which in most cases are easily treatable but in rare cases, 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 colour changes may not be noticeable for 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: The 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. The reuse of applicators increases the potential for contamination and infections.

  6. Do not apply Latisse to the 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 complications 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.

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