LATISSE / LUMIGAN REFILL   Medical Evaluation Form 

Latisse bimatoprost solution for male pattern baldnessLumigan bimatoprost solution for male pattern baldnessWelcome back.  After your initial consultation and LATISSE or Lumigan ophthalmic solution approval each follow-up consultation, if approved, is only $75 and includes  refill prescriptions good for 12  months.  If approved you are issued a written prescription for Latisse .03% 5 ml  bottle Ophthalmic Solution with 11 additional refills or Lumigan .01% 7.5 ml bottle with 11 additional refill prescriptions.

Hair growth is very slow and it takes up to 16 weeks to see results.   Male pattern hair loss  is a genetically determined condition and a life-long condition and you need to continue to use Latisse or Lumigan to maintain the benefits of enhanced hair growth. Please accurately and completely provide the following information in order for a physician to review your record. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. (If you don't have this available, you can Email us for your membership number.)
 
 

 NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Latisse  if approved.   Do NOT combine Latisse or Lumigan with other prescription eye drops for glaucoma or Intraoccular Pressure problems  Do not use if pregnant or nursing.  If the consulting physician determines that Latisse  Refills are not appropriate for you, there is NO charge for this consultation.

Click here  to read the stated conditions before filling out the medical consultation form: I have read the previous Latisse or Lumigan pages and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of Liability:YES NO
The medical information you supply is subject to ALL patient/doctor privilege laws.
MEDICAL HISTORY 
First and Last Name:

Medical Wellness Center Membership Number: 

SEX: Female  Male 
Date of Birth(MM/DD/YY):         Current Age: 
Height (inches):Weight:
  : 
Did you experience any side effects:YES NO 
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms: 
Describe your response to Latisse / Lumigan treatment and detail the progress. Detail how long before you started to notice changes  etc.
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition)
Please list all current Medical Conditions:

Do you take any prescription medication or use any prescription eye drops?YESNO
If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc.

Please list all over-the-counter drugs you take regularly and why. 
For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?YES NO
If Yes, please list any known Allergies to Medicines:

 Have you had a physical exam in the last two years?YES  NO 
 
Are allergic to Latisse, Lumigan, bimatoprost or any of the ingredients in Latisse or Lumigan? YES NO
Have you ever been diagnosed in the past with increased Intraoccular Pressure - Glaucoma? YES NO
Are you currently using any medication to treat glaucoma? YES NO
If yes, please list all prescription eye medications for glaucoma used: 
Are you currently using any prescription eye drops to treat IOP - Intraocccular Eye Pressure Conditions?YESNO
If yes, please list all prescription eye medications used: 
Are you currently pregnant or nursing? YES NO
Are you currently LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops in your eye ( Bimatoprost ophthalmic solution )YESNO
Are you currently being treated for cancer?YES NO
If yes, please explain: 
Do you smoke?YES NO 

How much alcoholic beverages do you drink?
None  Occasionally  Moderately  Heavily 
CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Glaucoma Increased Intraoccular Pressure Liver Disease
Jaundice Kidney Disease Eye Pressure Problems
Coronary Artery Disease Heart Attack Heart disease
High Blood Pressure Stroke Diabetes
Thyroid disease Depression
Are you currently taking steroids?YES NO
Are you currently being treated for cancer? 
YES NO 
If yes, please explain: 
Have you had surgery in the last 3 months? 
YES:NO 
If yes, please explain: 
Do you consider anything in your medical history to be relevant, please give details.
If unsure, please ask your regular doctor
PERSONAL and PAYMENT INFORMATION 
In order to review your consultation, you must provide your full name, a Physical Address (We do NOT accept requests to PO Boxes) and complete Phone number. We do NOT accept requests from Illinois or Arkansas or Florida
FULL NAME:
ADDRESS: (Physical Address Necessary 
We do NOT process any orders to PO BOX#'s)
CITY:
STATE:     ZIP CODE 
COUNTRY:
PHONE (REQUIRED):
EMAIL: (REQUIRED)
Please provide complete email, ie You@domain.com or name@aol.com 
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
EXPIRATION DATE(MM/YY):
Enter you credit card 3 digit security number. To find this number turn your card around and on the back on the strip where you sign your name there are some numbers printed. There are either a set of 4 numbers (the last 4 numbers of your credit card) and a set of 3 numbers, or just a set of 3 numbers. The set of 3 numbers is the security number that is necessary in order to process your request.
ENTER 3 Digit Security Code
BILLING ADDRESS:
BILLING ZIP CODE
I, AS THE CREDIT CARD HOLDER, VERIFY THAT I AM SUBMITTING THIS ONLINE-CONSULTATION REQUEST FOR A MEDICAL PRESCRIPTION AND I AUTHORIZE THE CHARGES STATED TO BE MADE TO MY CREDIT CARD (I understand that if I later dispute this charge as "unauthorized" I will be subject to criminal prosecution for credit card fraud). 
If credit card holder name is different than the person submitting consultation, you must verify that you have been given authorization to use this credit card:  I VERIFY THAT I HAVE BEEN GIVEN AUTHORIZATION BY CREDIT CARD HOLDER TO USE ABOVE CREDIT CARD.( I understand that if this charge is disputed by credit card holder as unauthorized, I will be subject to penalties of criminal prosecution for credit card fraud.)YES NO
AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida 
Medical Wellness Center does not sell or dispense any medications and we are not affiliated with any pharmacies. 
For pricing and price comparisons, you need to contact the pharmacy directly.

For refill prescriptions you have the option of:

1.  Receiving a WRITTEN prescription by mail which you can fill at most any local United States pharmacy of your choice (approximately 7- 15 days)

2.  Have your prescription called into your local U.S. pharmacy, COMPLEMENTARY call in service.

If you select option # 2, you can also select EXPRESS 24 hour processing where your prescription will be called into your local pharmacy  in approximately 24 hours.  If you select EXPRESS 24 hour processing you will be charged a $20 express processing service fee rather than the regular processing fee of $9.50. 
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee


Check only ONE of the two choices below:

1. Receive Written prescription:
Receive written prescription in approximately 7- 15 days which you can fill at most any local United States pharmacy of your choice.

2. Prescription called into your local pharmacy:
Prescription for one year of  refills called into any major local United States pharmacy of your choice rather than receiving a written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions  (unless you are choosing the Express Refill call in service) and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, please enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription (The prescription can only be called into your local U.S. pharmacy.  It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Amazon.com or an internet version of a local pharmacy such as CVS.com etc.) 

 
If you are choosing to have your prescription called into your local pharmacy, select whether you want Regular service or Express service.
REGULAR SERVICE:  No extra charge, regular processing fee of $9.50:  Prescription called into your pharmacy in 3 -7 days.
EXPRESS SERVICE:  $20 express processing fee  instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy in approximately 24 hours.
You can choose either to receive a prescription for Latisse 0.03% bimatoprost 5 ml bottle with  or Lumigan 0.01% 7.5 ml bottle:
Bimatoprost  is the active ingredient in both Latisse and Lumigan.  You can choose to receive a prescription for either a 5 ml bottle of Latisse 0.03% solution with 11 refills or a 7.5 ml bottle of 0.01% Lumigan solution with 11 refills.

Latisse 0.03% solution 5 ml bottle with 11  refills - one year of refills
Lumigan 0.01% solution 7.5 ml bottle with 11 refills - one year of refills

If you fail to make a selection in this above section you will by default be prescribed Latisse 5 ml bottle solution with 11 refills.


 
By submitting this consultation form, I certify:

I am a  18 years of age or older. 
I have read and agree to Waiver of Liability. 
I understand the side effects of this medication and adverse effect. 
I understand that Latisse / Lumigan  is not to be used by anyone under the age of 18. 
I understand that Latisse or Lumigan is NOT prescribed to women for hair thinning because women's hair loss or thinning can be due to an underlying life threatening medical condition and needs direct physician monitoring.
I understand that Latisse / Lumigan  is NOT to be used by pregnant or nursing woman. 
I am aware that I need to inform my doctor that I am using Latisse / Lumigan when going to an ophthalmologist and /or having my intraoccular pressure measured. 
I do not have any of the contraindications to therapy. 
I am not currently using any prescription eye drop medication for glaucoma or IOP -Intraoccular Pressure Problems 
I understand that I must NOT combine Latisse with  LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops 
I understand that my credit card will be billed $75.00 (plus S&P $9.50) for the medical  consultation if approved, if not approved there is no charge for the consultation.  I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $75.00 consultation fee plus S & P  if approved and understand that there are no refunds for any circumstances even if  I later change my mind and decide not to fill the prescription or take  the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee.  It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication.  Also, if a pharmacy refuses to fill a valid  prescription issued by Medical Wellness Center due  to do failure to verify your billing/shipping// & or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee. 

Please CONFIRM YOUR SELECTION made above of receiving written prescription  or your prescription called into a local U.S. pharmacy :

Option 1: Receive written prescription by mail in 7-15 days.
Option 2: Prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # below
 
If you are choosing (Option 2) to have your prescription called into your local pharmacy, please confirm selection of whether you want Regular service or Express service.
REGULAR SERVICE:  No extra charge, regular processing fee of $9.50:  Prescription called into your pharmacy in 3-7 days.
EXPRESS SERVICE:  $20 express processing fee  instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy in approximately 24 hours.

I have answered all the questions truthfully and I understand that by clicking submit I agree to all the terms and conditions including that my credit card will be charged the above stated amount for the consultation if approved.


Click SUBMIT button for Physician Consultation for Latisse / Lumigan Solution REFILLS
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. 

For any questions
email at wellnessmd@medicalwellnesscenter.com
Email to contact Medicall Wellness Center: Latisse Eyelash SolutionTo contact Medical Wellness Center -  with any questions, please Email us.
PHONE  NUMBER: 
(US ONLY)		 617-367-8887
Medical Wellness Center 
Boston, MA

Medical Wellness Center