Indications – Prescription treatment for hypotrichosis used to grow eyelashes.

LATISSE SCREENING INTERVIEW

1. Do you use Lumigan or any other medication to treat intraocular pressure? …..Y …..N
2. Are you pregnant or breastfeeding? …..Y …..N
3. Do you experience any of the following symptoms / conditions:
   a. Eye pruritus (itchy eyes) …..Y …..N
   b. Conjunctival hyperemia (red eyes) …..Y …..N
   c. Irritated eyes …..Y …..N
   d. Dry eyes …..Y …..N
   e. Eyelid redness …..Y …..N
   f. Twitching eyelids …..Y …..N
   g. Macular edema …..Y …..N
4. Do you have brown spots or discoloration of the eyelids? …..Y …..N

If you answered Yes to #1 or #2, you may not use Latisse.

If you answered Yes to any part of #3, we recommend you see your Opthamologist to correct and control your symptoms prior to starting Latisse.

If you answered Yes to #4, we recommend you see your Dermatologist before starting Latisse.

Latisse warnings, precautions and adverse reactions:

1. Do not use Latisse with other medications that lower Intraocular Pressure (IOP).
2. May cause permanent iris pigmentation if Latisse comes in continual contact with your eye.
3. Latisse may cause hyper pigmentation of the eyelid. This is reversible after stopping Latisse.
4. It is very important to apply Latisse to skin of upper eyelid margin at the base of the eyelashes to reduce the potential of unwanted hair growth outside treatment area.
5. Do not use Latisse if you have Macular edema.
6. Avoid contaminating Latisse applicators.
7. Do Not use if pregnant or breastfeeding.
8. Remove contact lenses prior to applying Latisse. Resume use of contact lenses 15 minutes after Latisse dries.
9. Red eye or conjunctal hyperemia will usually resolve in a few days to two (2) weeks. If it persists or suddenly worsens, discontinue Latisse.
10. Less than 4% of patients experience eye pruritus (itch), skin hyperpigmentation (darkening), ocular (eye)
    irritation, dry eye, Erythema (redness) of eyelids.

If these symptoms do not resolve in a few days, then discontinue Latisse and / or see your Ophthalmologist.

***Non-refundable – Latisse is a prescription drug – cannot be returned.****

The above statement has been discussed with me including risks, benefits and/or alternatives. All of my questions have been satisfactorily answered. Additional written information has been provided to me upon request. I understand and accept the potential risks of the product.