MEDICAL QUESTIONNAIRE

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

How did you hear about us? *

Instagram

Facebook

Word of mouth

Google search

Wrinkle Dr client

Magazine

Other

Is there any possibility that you are pregnant or breast feeding? *

Yes

No

Have you ever used Latisse / Lumigan eye drops before? *

Yes

No

If yes, have you had any side effects or problems? *

If you have suffered from any side effects, please email Dr Hayward on info@theeyelashdr.co.uk.

Yes

No

Do you suffer from any eye problems such as glaucoma, macular oedema or iritis? *

Yes

No

Are you under the care of an ophthalmologist? *

Yes

No

Do you use any prescription eye drops on a regular basis? *

Yes

No

Do you wear contact lenses? *

Yes

No

Do you suffer from any known allergies? *

Yes

No

I am aware that potential side effects although rare can include eye irritation (4%), eyelid pigmentation and pigmentation of the iris (if you have pale coloured eyes). *

If you have blue of hazel coloured eyes, please take extra care watching out for pigmentation of the iris.

Yes

I understand that rarely the drops may cause eye irritation or eyelid hyperpigmentation, which is usually reversible on discontinuation of the product. *

Yes

I know to stop using the drops immediately if any pigmentation changes occur in the iris portion of my eye which can be permanent. *

Yes

I accept full responsibility for any adverse reactions that may occur. *

Yes

I confirm that these eye drops items are for my own personal use. *

Yes

I confirm I have read the 'Application' page on the Eyelash Dr website explaining how to apply the drops and, by clicking this box, accept full responsibility for using Lumigan and any possible side effects that may occur. *

Yes