Name: Suddenly Slimmer Med Spa
Price range: $$

Latisse is a prescription treatment approved by the FDA to grow longer, thicker, and darker eyelashes.
Latisse is believed to affect the growth phase of the eyelash hair cycle in 2 ways; first, it increases the length of the “growth”
phase; and second, it increases the number of hairs in the “growth” phase. The exact way in which Latisse works is still
unknown.

The onset of results is gradual but usually, a significant improvement is noted after 2 months of nightly use.
You should not use Latisse solution if you are allergic to one of its ingredients. Also, it is important to let your physician know if
you answered “yes” to any of the following questions.

Full Name*
Date of Birth: mm/dd/yyyy*
Address:*
City:*
State:*
Zipcode*
Email:*
What medical conditions do you have, if any?*
What medications are you currently taking?*
Do you have any drug allergies?*
Are you pregnant, nursing, or taking fertility drugs?*
Any other medical condition or information that we need to know?*
Have you ever been diagnosed with the following conditions?*
- Hypersensitivity to Latisse/Lumigan/Bimatoprost
- Ocular Inflammation
- Third Choice
- Glaucoma
- Aphakia
- Macular Edema
- Increased Intraocular pressure
- None Of The Above
Informed Consent
I request and consent to receive Latisse eyelash enhancer for the purpose or lengthening, thickening, and darkening my eyelashes. I understand that as part of the program I will be given the Latisse formula with supporting materials and will be instructed on how to administer the drops myself. I understand that initial intake form will be necessary to rule out any conditions that would disqualify me from the program. I will obtain this form from Suddenly Slimmer Day Spa. I understand Latisse is FDA approved for lengthening, thickening, and darkening of the eyelashes. I agree that I am, and will be under the care of another medical provider for all other conditions. Suddenly Slimmer Day Spa can work in conjunction with, but cannot replace, regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand the physicians with Suddenly Slimmer Day Spa only prescribe Latisse for the treatment of lengthening, thickening, and darkening eyelashes. Suddenly Slimmer Day Spa does not accept or bill insurance for this program. Prior to my treatment, I have fully disclosed any medical conditions or diseases such as: pregnancy, breastfeeding, history of glaucoma, aphakia (absence of lens in the eye), macular edema, ocular inflammation, hypersensitivity to Latisse (or bimatoprost), or other serious medical condition. Any contraindications for the use of Latisse have been fully disclosed to me. I understand that use of Latisse is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform Suddenly Slimmer Day Spa if I am pregnant, could be pregnant, or should become pregnant during the course of the treatments. While Latisse is mostly free of negative side effects with any medication there is the possibility of an allergic reaction or unusual reactions that may cause conjunctival hyperemia (redness of eyes), itchy eyes, dry eyes, visual disturbances, ocular blurring, foreign body sensation, periorbital skin darkening, blepharitis, keratitis, eyelid erythema, ocular irritation, iris discoloration, or photophobia.. I understand that the medications may involve risk. I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that there are risks involved as there are with all medications and that not complying with the dosage recommendations could increase risks and alter my results from the program. I understand that I may quit the program at any time. No adverse side effects or complications are expected, but in the event that an illness does occur, I understand that I need to contact Suddenly Slimmer Day Spa. If I experience an emergency situation, I understand that I need to go to an emergency facility. Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this treatment. I will also inform Suddenly Slimmer Day Spa of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments. I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.
Your typed name below is equivalent to your signature.

Latisse Intake Form

Informed Consent