Eye Lash & Eye Brow Bimatoprost 0.03%

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Address(Required)

Street Address City ZIP / Postal Code Country

Email(Required)

Phone Number(Required)

Do you have any known allergies, especially to prostaglandins or eye drops?(Required)

Yes

If Yes, please specify

Have you ever been diagnosed with any of the following eye conditions? (Tick all that apply)(Required)

Glaucoma

Dry Eye Syndrome

Uveitis or iritis

Eye infections

Retinal conditions (e.g., macular degeneration)

None of the above

Other

Other, please specify

Have you ever had eye surgery or laser eye treatment?(Required)

Yes

If yes, please provide details:

Do you have a history of eye pressure problems (e.g., high or low intraocular pressure)?(Required)

Yes

If yes, please provide details:

Do you have any of the following medical conditions? (Tick all that apply)(Required)

Uncontrolled high or low blood pressure

Heart disease

Liver disease

Kidney disease

Diabetes

Autoimmune disorders

None of the above

Are you currently pregnant, planning to become pregnant, or breastfeeding?(Required)

Yes

Are you currently using any eye drops or other treatments for your eyes?(Required)

Yes

If yes, please list:

Have you ever used Bimatoprost or similar eyelash growth products before?(Required)

Yes

If yes, did you experience any side effects?

Are you taking any prescription or over-the-counter medications, including supplements?(Required)

Yes

If yes, please list:

Do you understand that Bimatoprost 0.03% is an unlicensed treatment for eyelash growth, meaning it has not been officially approved for this purpose but is prescribed based on clinical judgment?(Required)

Yes

Do you understand that improper use may lead to side effects such as eye redness, itching, darkening of the eyelid skin, or permanent darkening of the iris?(Required)

Yes

Do you understand that this medication should only be applied to the upper eyelid lash margin and not to the lower eyelashes or directly into the eye?(Required)

Yes

Do you agree to follow the prescriber's instructions and to discontinue use if you experience any adverse effects?(Required)

Yes

Final Declarations(Required)

I confirm

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this treatment is prescribed based on the information I have provided. I consent to my information being reviewed by a registered prescriber.

Please note: Your order is NOT confirmed yet. All orders require prescriber approval before dispatch. If your application is NOT approved, we will issue a FULL refund. If approved, your product will be dispatched, and you will receive an email confirmation. If you have any questions, contact our support team at 0208 191 3034.(Required)

I understand

Please note: Your order is NOT confirmed yet.
All orders require prescriber approval before dispatch.
If your application is NOT approved, we will issue a FULL refund.
If approved, your product will be dispatched, and you will receive an email confirmation.
If you have any questions, contact our support team at 0208 191 3034.

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Eye Lash & Eye Brow Consultation Form

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