Patient Information

Are you older than 18 years old?

For females, are you pregnant or breastfeeding?

Patient Symptoms

Do you have sparse and short eyelashes?

Medical History

Do you have allergies to bimatoprost, latanoprost, Eyerida, Zimed, or silver?

Have you had a history of any of the following?

• Closed-angle glaucoma
• Retinal detachment
• Loss or torn eye lens
• Problems in your cornea (outer layer of the eye)
• History of inflammation (uveitis, iritis) or viral infection (herpes simplex) of the eye
• Eye lens replacement surgery
• Asthma or chronic obstructive pulmonary disease

Are you taking latanoprost medication for your eyes?

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber