Latisse Intake & Consent Form

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Latisse Consent Form

I understand that I will be given a prescription for Latisse (bimatoprost ophthalmic solution), which is indicated for the treatment of hypotrichosis (inadequate or insufficient eyelashes). Latisse works by increasing eyelash growth, including length, thickness, and darkness.

A. Contraindications Hypersensitivity 1. Patients with hypersensitivity to bimatoprost or any other ingredient in this product Pregnancy 1. While there are no adequate and well controlled studies for bimatoprost in pregnant woman Latisse should not be administered during pregnancy since the potential benefit does not justify the potential risk to the fetus. 2. Nursing mothers should not take Latisse since many drugs are excreted in human milk. 3. Contact Lenses Latisse solution may be absorbed by soft contact lenses. Contact lenses should be removed prior to application of solution and may be reinserted 20 – 30 minutes following its use.

B. The possible side effects of Latisse include but are not limited to: 1. Risks: I understand there is a risk of itching, increased blood in the eye, hyperpigmentation of the skin, irritation, dry eyes, redness, allergic reaction. 2. Infection: Infections can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur. 3. Iris Pigmentation: Increased iris pigmentation has occurred. You should be advised that the potential for increased brown iris pigmentation is likely to be permanent should this side effect occur. Iris color changes may not be noticeable for several months to years. 4. Lid Pigmentation: Bimatoprost has been reported to cause pigment darkening of the eyelid. This side effect has been reported to be reversible upon the discontinuation of treatment. 5. Intraocular Inflammation: Latisse solution should be used with caution in individuals with active intraocular inflammation (uveitis) because the inflammation may increase. 6. Macular Edema: Swelling of the small area of the retina responsible for central vision. The edema is caused by fluid leaking from the retinal blood vessels.

C. Use 1. Latisse must be used exactly as directed to reduce the risk of complications and side effects. 2. The Latisse bottle must be kept intact during use. 3. Place one drop on the single use per eye applicator. 4. Bottle tip should never be allowed to contact any other surface to avoid contamination 5. Sterile applicators may only be used on one eye and then discarded. Reuse of applicators increases the potential for contamination and infections. 6. Do not apply Latisse to bottom lashes 7. Do not use Latisse more than once per day. Additional application will not increase results but will increase the risk of possible complication and side effects. 8. Upon discontinuation of Latisse eyelash growth is expected to return to its pre-use level 9. Do not use Latisse on any other areas of the body. Studies have not been performed as to the safety and effectiveness in any area other than the eyelashes.

By signing below, I acknowledge that I have read and fully understand the foregoing informed consent, and I agree to proceed with the treatment along with its associated risks. I hereby release the clinical team and overseeing physician, as well as Anastasija Medical Aesthetics, from any liability related to this procedure.

I further understand that failure to follow the above listed instructions and appropriate use of Latisse may result in infection and permanent injury. I have discussed any questions I have about Latisse and its use with the doctor or nurse.

Signed in Ontario

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About Latisse & After Care Instructions

Bimatoprost topical solution

Read this carefully before you start taking LATISSE and each time you get a refill. This leaflet is a summary and will not tell you everything about this drug. Talk to your healthcare professional about your medical condition and treatment and ask if there is any new information about LATISSE.

What is LATISSE used for?

LATISSE is used to treat hypotrichosis (less than normal hair) of the eyelash to increase the length, thickness and darkness of eyelashes.

How does LATISSE work?

LATISSE is believed to lengthen the growth period of your eyelashes and increasing the number of lashes involved in the growth phase. This results in longer, fuller and darker eyelashes.

What are the ingredients in LATISSE?

Medicinal ingredients: bimatoprost
Non-medicinal ingredients: benzalkonium chloride as preservative, citric acid monohydrate, sodium chloride, sodium phosphate dibasic heptahydrate and purified water. Hydrochloric acid and/or sodium hydroxide may be added to adjust pH.

LATISSE comes in the following dosage forms:

Topical solution 0.03%, w/v

Do not use LATISSE if:

You are allergic to bimatoprost, to any of the other ingredients, or to any of the parts of the container (see section What are the ingredients in LATISSE?).

To help avoid side effects and ensure proper use, talk to your healthcare professional before you take LATISSE. Talk about any health conditions or problems you may have, including if you:

have no visible eyelashes. Your doctor will consider any underlying conditions to determine whether this product is appropriate for you
are taking, or have recently taken, any other medicines. Using LATISSE with other medicines or bimatoprost products may reduce their effectiveness.
are pregnant or are planning to become pregnant
are breastfeeding or planning to breastfeed. Ask your doctor about how to feed your baby while using LATISSE
have an active eye infection, inflammation (e.g. uveitis) or any other eye or eyelid condition
need to have eye surgery

Other warnings you should know about:

LATISSE use has been associated with iris pigmentation (change in the coloured part of the eye). This is likely to be permanent. To help avoid pigmentation, it is extremely important to strictly observe the following measures:

Changes in eye and eyelid colour:

Do not apply directly in the eye.
Do not add more than one drop to an applicator.
Blot any excess solution outside the upper eyelid margin with a tissue or other absorbent material.
Do not administer the medication more than once daily.
Do not apply to the lower eyelash line.
Do not use the same applicator for more than one eye.
Do not reuse applicators.
Do not alter the applicator in any form.
Do not use any other brush/applicator to apply LATISSE

Using too much LATISSE may contribute to iris pigmentation. LATISSE use may also cause darkening of the eyelid skin which may be reversible in most patients (see Overdose section).

Hair growth:

It is possible for hair growth to occur in other areas of your skin that LATISSE frequently touches. Any excess solution outside the upper eyelid margin should be blotted with a tissue or other absorbent material to reduce the chance of this from happening. It is also possible for a difference in eyelash length, thickness, fullness, pigmentation, number of eyelash hairs, and/or direction of eyelash growth to occur between eyes. These differences, should they occur, will usually go away if you stop using LATISSE.

Changes in vision:

Application of LATISSE may temporarily blur your vision. Do not drive or use machines until your vision has cleared.

Tell your healthcare professional about all the medicines you take, including any drugs, vitamins, minerals, natural supplements or alternative medicines.

If you are using LUMIGAN or other products in the same class for elevated intraocular pressure (IOP), or if you have a history of abnormal IP, you should only use LATISSE under the close supervision of your doctor.

The following may interact with LATISSE:

No specific drug interaction studies have been done with this medication.

How to take LATISSE:

DO NOT APPLY in your eye or to the lower lid. ONLY use the sterile applicators supplied with LATISSE to apply the product. Do not reuse or modify applicators and do not use any other brush/applicator to apply LATISSE. Fifty percent of patients treated with LATISSE in a clinical study saw significant improvement by 2 months after starting treatment.
If LATISSE solution from a single dose gets into the eye, it is not expected to cause harm. Don’t allow the tip of the bottle or applicator to contact surrounding structures, fingers, or any other unintended surface in order to avoid contamination by common bacteria known to cause infections.
LATISSE contains a preservative called benzalkonium chloride which may discolour soft contact lenses if the eye is exposed. If you wear contact lenses, remove them before using LATISSE. They may be reinserted 15 minutes after LATISSE application.
Always use LATISSE exactly as your doctor has instructed you.

Follow these steps to use LATISSE properly:

Clean your face and ensure that makeup and contact lenses are removed (see Illustration 1).
Remove an applicator from its tray. Then, holding the sterile applicator horizontally, place ONLY one drop of LATISSE on the area of the applicator closest to the tip but not on the tip (see Illustration 2).
Immediately draw the applicator carefully across the skin of the upper eyelid margin at the base of the eyelashes (where the eyelashes meet the skin) going from the inner part of your lash line to the outer part (see Illustration 3).
Blot any excess solution beyond the eyelid margin (see Illustration 4).
Dispose of the applicator after one use (see Illustration 5).
Repeat for the opposite upper eyelid margin using a NEW sterile applicator. This helps minimize any potential for contamination from one eyelid to another.

Usual dose:

The recommended dosage is one application nightly to the skin of the upper eyelid margin of each eye at the base of the eyelashes only.

Use of LATISSE more than once a day is not expected to increase the growth of eyelashes more than use once a day.

Overdose:

Overdosing (putting more than one drop on the applicator) may result in an increased chance of iris pigmentation (IP). Any extra solution outside the upper lid margin should be blotted with a tissue. If LATISSE solution from a single dose gets into your eyes, it is not expected to cause harm.

If you think you, or a person you are caring for, have taken too much LATISSE, contact a healthcare professional, hospital emergency department, or regional poison control centre immediately, even if there are no symptoms.

Missed Dose:

If you miss a dose, don’t try to “catch up.” Just apply LATISSE solution the next evening. Do not double dose.

What are possible side effects from using LATISSE?

These are not all the possible side effects you may have when taking LATISSE. If you experience any side effects not listed here, tell your healthcare professional. Like all medicines, LATISSE can have side effects. Most of the side effects are not serious. The most common side effects after using LATISSE solution are an itching sensation in the eyes and/or eye redness. This was reported in approximately 4% of patients. LATISSE solution may cause other less common side effects which typically occur on the skin close to where LATISSE is applied, or in the eyes. These include skin darkening, iris pigmentation, eye irritation, peeling of skin, deepening and drooping of the eyelid, dryness of the eyes and redness of the eyelids.

Cancellation policy

Dear Patient/Client:

We strive to render excellent care to you and the rest of our patients and clients. Your care and treatment is a priority to us. We also ask that you respect your nurse injector’s time and expertise as well.

In an attempt to be consistent with this, we have a Medical Appointment Cancellation Policy that allows us to schedule appointments for our patients, with respect for your time, the next patient’s time, the nurse practitioner’s time, and the nurse injector’s time.

Our policy is as follows:

We request that you give 24 hours’ notice in the event that you cannot make it to your scheduled appointment. If a patient misses an appointment without contacting our office, it is considered a missed or “No Show” appointment. A fee as shown below will be charged to your credit card, depending on the type of appointment missed. Additionally, if a patient is more than 15 minutes late for an appointment, it will be considered a “no show” appointment, and that appointment will be rescheduled. Also, if you miss more than 3 appointments, Anastasija Medical Aesthetics reserves the right to discharge you from the practice for failing to follow treatment recommendations.

If you have any questions regarding this policy, please let our staff know, and we will be happy to clarify the policy for you.

We look forward to being a part of your continued wellness.

Terms

I have read and understand the Medical Appointment Cancellation Policy of Anastasija Medical Aesthetics, and I agree to be bound by its terms. I am aware that my credit card will be charged $50.00 for the missed appointment, and I agree to these terms.

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