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Latisse Consent

LATISSE by Allergan

LATISSE is a treatment for hypotrichosis (having inadequate or not enough eyelashes).  This once daily prescription medication will enhance the length, thickness, and darkness of eyelashes in as little as eight weeks, with full results at sixteen weeks.

Safety Information

Apply LATISSE once daily at night to the skin of the upper eyelid margins at the base of the eyelashes using the FDA approved applicator.  DO NOT APPLY to the lower eyelid.   

 LATISSE may cause:

•  Darkening of the eyelid skin, which may or may not be reversible

•  Increased brown pigmentation of the iris (colored part of the eye) which is likely to be permanent

•  Hair growth in other areas of your skin that LATISSE touches

Common side effects:

•  Eye Redness (3.6%)

•  Itchy Eyes (3.6%)

•  Skin Hyperpigmentation (2.9%)

•  Iris Color Changes / Darkening (?%)

 Treatment Plan- recommended visits (not covered by medical insurance)

•  Initial office visit to discuss goals, obtain baseline measurements, and instruct on usage and side effects.   $55

•  Second office visit recommended at 6-8 weeks to observe results and discuss any adverse effects. $55

•  Third office visit recommended at 16 weeks to confirm results and discuss effects.  $55

•  Routine annual examination thereafter.

I have read the above information and understand the possible side effects that may occur with use of LATISSE.  I also understand two to three office visits (which are not covered by insurance) are required to obtain and refill a prescription for the medication.         

 

Patient Name:             ______________________________________________

Date:                           ______________________________________________

Signed:                        ______________________________________________

Go to www.latisse.com for more information (application, tips, and testimonials).