Before Proceeding to the Latisse / Lumigan Medial Consultation Form please read
CONTRAINDICATIONS and WARNINGS
and accept the Waiver of Liability
In order for Medical Wellness Center Physicians to provide you with the best care you need to reply honesty to all questions and you need to understand any and all risks and side effects associated with Latisse.
CONTRAINDICATIONS:
  • Anyone who is allergic to any one of the ingredients in Latisse or Lumigan (bimatoprost):  Active ingredient - bimatoprost. Inactive ingredients - benzalkonium chloride; sodium chloride; sodium phosphate, dibasic; citric acid; purified water. 
  • Do NOT use Latisse / Lumigan (bimatoprost) if you have problems with intraoccular pressure - have glaucoma or have had glaucoma in the past.
  • Do NOT use Latisse / Lumigan (bimatoprost) if you are currently using any type of eye drops for glaucoma or intraoccular pressure problems. Using Latisse (bimatoprost) can decrease the effectiveness of other glaucoma eye drops such as LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs
  • Do NOT use Latisse / Lumigan (bimatoprost)  if you are pregnant or nursing
  • Do NOT use if you are under age 18.
IMPORTANT WARNING:
When visiting your ophthalmologist or are having your Intraoccular eye pressure measured, always inform the physician that you are using Latisse/ Lumigan  (bimatoprost).

LATISSE / LUMIGAN (bimatoprost)  SOLUTION SIDE EFFECTS:

Side effects are rare.  The most common side effects is an itching or redness

Other side effects less common can be skin darkening, hyperpigmentation of the upper skin where Latisse / Lumigan (bimatoprost) is applied. This skin color change is believed to be reversible when medication stopped.  Other side effects may include eye irritation, dryness of the eyes and redness of skin.

Although never reported with Latisse, when the same active ingredient is used in the eye itself to treat glaucoma, it can lead to irreversible darkening of the colored part of your eye, the iris.

IMPORTANT INFORMATION:

Latisse / Lumigan is NEVER to be used in the eye when prescribed for cosmetic hair loss 
Latisse is to be applied topically ONLY to the upper eyelash area or to the scalp.
Latisse / Lumigan is NOT to be used more than once a day.
Latisse is ALWAYS to be applied with the FDA-approved applicators only to prevent contamination when used for eye lash thickening
Always blot excess Latisse - unwanted hair growth can occur if repeatedly applied to an area

Latisse / Lumigan  (bimatoprost) is SAFE when used as directed!

I DO NOT HAVE ANY OF THE ABOVE CONTRAINDICATIONS:
By accepting "I Agree" means that you have read the above contraindication and warnings and honestly acknowledge that you do not have any of the above contraindications to Latisse/ Lumigan therapy and understand that insurance will not cover the cost of the medication.  Also, that I am aware that I need to inform my doctor that I am using Latisse / Lumigan when I go to the ophthalmologist or have my intraoccular pressure measured.
Latisse I agree - proceed to waiverLatisse I disagree

 
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