Before Proceeding to the  Latanoprost(Xalatan) 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 Latanoprost.
CONTRAINDICATIONS:
  • Anyone who is allergic to any one of the ingredients in Latanoprost (Xalatan):  Active ingredient - latanoprost.  Inactive ingredients - Benzalkonium chloride, 0.02%, sodium chloride, sodium dihydrogen phosphate monohydrate, disodium hydrogen phosphate anhydrous, and water . 
  • Do NOT use Latanoprost (Xalatan) if you have problems with intraoccular pressure - have glaucoma or have had glaucoma in the past.
  • Do NOT use Latanoprost (Xalatan) if you are currently using any type of eye drops for glaucoma or intraoccular pressure problems. Using topical Latanoprost (Xalatan) can decrease the effectiveness of other glaucoma eye drops such as LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs
  • Do NOT use Latanoprost (Xalatan) 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 topical Latanoprost (Xalatan).
DO NOT PUT IN YOUR EYES - TO BE USED TOPICALLY ON SCALP ONLY FOR MALE PATTERN HAIR LOSS!

LATANOPROST (XALATAN)  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 Latanoprost (Xalatan) is applied. This skin color change is believed to be reversible when medication stopped or it may possibly be permanent?  Other side effects may include eye irritation, dryness of the eyes and redness of skin.

Although not reported with Latisse or topical Latanoprost (Xalatan), 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.

Very serious allergic reactions to this drug are rare.  However, if you notice any symptoms of a serious allergic reaction such as rash, severe itching/swelling (especially of face/tongue/throat), dizziness or trouble breathing SEEK IMMEDIATE EMERGENCY MEDICAL HELP!

This list is not a complete list of possible side effects.  If you notice other effects not listed above, contact your primary care physician or pharmacy.

IMPORTANT INFORMATION:

Latanoprost (Xalatan) is NEVER to be used in the eye when prescribed for cosmetic hair loss 
Latanoprost (Xalatan) is to be applied topically ONLY to the scalp.
Latanoprost (Xalatan) is NOT to be used more than once a day.
Always blot excess Latanoprost (Xalatan) - unwanted hair growth can occur if repeatedly applied to an area

Latanoprost (Xalatan)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 Latanoprost (Xalatan) 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 Latanoprost (Xalatan)when I go to the ophthalmologist or have my intraoccular pressure measured.
Latanoprost (Xalatan) I agree  - proceed to waiver Latanoprost (Xalatan) I disagree

 

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