Latisse Eligibility Form

Quanity ($126.60 + $6.00 shipping per bottle)
Total: $132.60
First Name (required)
Last Name (required)
Phone (required)
Email (required)
Medical Constent Form (required)
I have read, reviewed & understand all of the information provided on the FAQs page and am informed and knowledgable about LATISSE®
Consent to Treat (required)
Yes, I Accept & Agree to be Treated by Advanced Cosmetic Solutions. My typed name above is equivalent to my signature and is my consent for you to treat me as your patient.
I Waive (required)
Yes, I certify, understand and Waive/Decline the option to be seen in person for a medical evaluation.
I Certify (required)
Yes, I certify that all of the information provided by me here is true and correct and I agree to use LATISSE® as intended and directed.
I hereby Accept & Release (required)
Yes, I Accept & Agree to Release & Hold Harmless Advanced Cosmetic Solutions of any and all liability in connection with the usage of LATISSE®.
HIPAA Privacy Notice (required)
Yes, I have read and agree to the HIPAA Privacy Notices.
To protect Us & You, You Accept (required)
Yes, I will not dispute the credit card charges after I receive LATISSE®, I also accept UPS and/or USPS Delivery Confirmation as proof of LATISSE® delivery to me.
I Certify (required)
Yes, I certify that I am at least 18 years old.
Have you ever used LATISSE® in the past? (required)
Are you allergic to any of the active ingredients in LATISSE®? (required)
Currently Pregnant? (required)
No, I am NOT currently pregnant, nursing, or planning on getting pregnant while using LATISSE®.
Have you had any surgeries? This includes any eye surgery. If so, please list them here. (required)
Do you have any allergies? Please list all your medication allergies (if any) here (required)
What Medical or Eye Conditions do you have that you are currently being treated for? This includes Eye or Other medications you are currently using (required)
Would you like to stay informed about new promotions/discounts? (required)

Credit Card Information

Credit Card Number (required)
Exp. Date (required, MMYY)
CVV Security Code (required)

Billing Address

Street Address (required)
City (required)
State / Province (required)
Zip / Postal Code (required)
Country (required)

Shipping Address

If shipping address is the same as billing address, please leave following fields blank.

Street Address
City
State / Province
Zip / Postal Code
Country

Coupons

Coupon Code (required)