I am 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication and adverse effect.
I understand that Latisse (Bimatoprost) is not to be used by anyone under the age of 18.
I understand that Latisse (Bimatoprost) is NOT prescribed to women for hair thinning because women's hair loss or thinning can be due to an underlying life threatening medical condition and needs direct physician monitoring.
I understand that Latisse (Bimatoprost) is NOT to be used by pregnant or nursing woman.
I am aware that I need to inform my doctor that I am using Latisse (Bimatoprost) when going to an ophthalmologist and /or having my intraoccular pressure measured.
I do not have any of the contraindications to therapy.
I am not currently using any prescription eye drop medication for glaucoma or IOP -Intraoccular Pressure Problems
I understand that I must NOT combine Latisse with LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops
I understand that my credit card will be billed $75.00 (plus S&P $9.50 or $20) for the medical consultation if approved, if not approved there is no charge for the consultation. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $75.00 consultation fee plus S & P if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to fill the prescription or take the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee. It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication. Also, if a pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to do failure to verify your billing/shipping// & or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee.
I have answered all the questions truthfully,and I understand that by clicking submit I agree to all the terms and conditions including that my credit card will be charged the above stated amount for the consultation if approved

Latisse Lumigan Refill Form