Latisse:  Medical Evaluation Form 
Latisse Eyelash Prescription for thick, long, beautiful eyelashesPlease 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. If approved you are issued a written prescription for Latisse Ophthalmic Solution  with 6 additional refill prescriptions.  We do NOT sell or ship medication.  If the consulting physician determines that Latisse is not appropriate for you, there is NO charge for this consultation. 
 

Choices:

  1. Regular Service: receive a written prescription and have it filled at most any local United States pharmacy of your choice
  2. Express Service:  Your prescription is called into your  local United States pharmacy of your choice an approximately 24 hours or less
NOT AVAILABLE IN ILLINOIS , ARKANSAS, and  FLORIDA
Click here  to read the stated conditions before filling out the medical consultation form: I have read the previous Latisse 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:
SEX: Female  Male
Date of Birth(MM/DD/YY):         Current Age: 
Height (inches):Weight:

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, bimatoprost or any of the ingredients in Latisse? 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 )YES NO
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
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 

You can choose to fill your prescription and your local United States pharmacy. 
In addition you can choose  either Regular or 24 hour Express Service:

You can choose to receive a written prescription and fill your prescription at most any local  United States pharmacy of your choice or  EXPRESS service and have your prescription called into the local United States pharmacy of your choice.

Our prescriptions can only be filled at a local United States pharmacy of your choice, they can not be filled at internet or foreign or Canadian or internet versions of pharmacies. 
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.
 


Choose whether you want regular service (7-15 days) or Express 24 hour service.

REGULAR SERVICE:  Consult reviewed within approximately 3-7 business days and your will receive a written prescription by mail in approximately 7- 15 days which you can take to most any local United States pharmacy of your choice and fill. Processing fee $10.35
EXPRESS SERVICE:  Consult reviewed and prescription within approximately 24 hours called into most any local United States pharmacy of your choice. Express processing fee $20.
Please check here if you are  requesting  our EXPRESS  review and processing of your  medical evaluation.  If approved  your prescription will be called into your  LOCAL United States  pharmacy of your choice within 24 hours.  If you checked yes and you are approved  you will be billed a $20 express processing fee. 
IF YOU ARE REQUESTING EXPRESS SERVICE CALLED INTO A PHARMACY MAKE SURE YOU ENTER THE NAME, ADDRESS AND PHONE NUMBER OF YOUR LOCAL UNITED STATES PHARMACY BELOW
If you are requesting express service, please enter 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. 
 
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 is not to be used by anyone under the age of 18.
I understand that Latisse 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 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 $49.95 (plus S and P $10.35) 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 $49.95 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. 

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.
 

Please CONFIRM YOUR SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy: 
Option 1 : Regular Service - receive written prescription by mail in 7-15 days
Option 2 : EXPRESS Service - have prescription called into a local U.S. pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
 


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

For any questions 
email at wellnessmd@medicalwellnesscenter.com
PHONE  NUMBER: 
(US ONLY)		 617-367-8887
Medical Wellness Center 
Boston, MA

 

Email to contact Medical Wellness Center -Latisse Eyelash SolutionTo contact Medical Wellness Center with any questions, please Email us.
 
Medical Wellness Center