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Why LATISSE? You may have seen over the counter products that condition lashes. LATISSE is different. It is the first and only product FDA approved to grow lashes fuller, longer, and darker for people with inadequate or not enough lashes. Now in a 5ml size for better value.

This is a prescription product. You must complete all Good Faith Exam documentation forms and protocols in order for us to complete this order.

1. Fill out HIPAA, Good Faith Exam, and Latisse Consent forms online by clicking the Required Forms tab above

2. We will review your submission and contact you within 24 hours

If you have any questions, please call us at 510-522-7487 or email

Active: Bimatoprost 0.3 mg/mL Preservative: Benzalkonium chloride 0.05 mg/mL Inactives: Citric acid; purified water; sodium chloride; sodium phosphate, dibasic. Sodium hydroxide and/or hydrochloric acid may be added to adjust pH. The pH during its shelf life ranges from 6.8-7.8.

Apply once nightly directly to the skin of the upper eyelid at the base of the eyelashes using only the accompanying sterile disposable applicators. Refer to enclosed leaflet for additional information. DO NOT reuse applicators and do not use any other brush/applicator to apply Latisse. DO NOT apply to lower eyelid. If you have a history of abnormal IOP, you should only use Lastisse under the close supervision of your doctor. Store at 36-77 degrees Fahrenheit (2-25 degrees Celsius)

  • HIPAA Patient Form

    The following is a required "notice of privacy practices" (NPP) in keeping with Federal and State HIPAA requirements.
  • Overview of privacy issues:

  • The laws regarding privacy of personal health information are complicated. Federal regulations require your approval of a full NPP as part of receiving health services. To accomplish this, I will provide you with a copy of the full, legally required NPP and this shorter version, which summarizes the same information. Finally, there is a standard consent form that documents your agreement with the NPP. I am not permitted to provide treatment without an executed consent form. You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these. The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, in the law, "health care operations." Before private information can be disclosed (sent, shared, or re1eased) for any additional purposes, a separate authorization form is required to allow it.
  • Your health information is private and will be kept that way, but there are some times when the law requires disclosure. For example:
    1. When there is a serious threat to your health or safety or the health or safety of another individual or the public. Information would then be shared with a person or organization that is able to help prevent or reduce the threat.
    2. Some lawsuits and legal or court proceedings.
    3. If a law enforcement official requires to do so.
    4. For Workers Compensation and similar benefit programs.
    5. There are some other situations like these but which happen very rarely. They are described in the longer version of the NPP.
  • Your rights regarding your health information:

    1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy. For example, you could ask me to call you at home and not a work to schedule or cancel an appointment. I will try my best to do as you ask.
    2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends. If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.,
    3. You have the right to look at your health information, such as billing records or health records associated with your skin care. You can even get a copy of these, provided that you reimburse your provider for time and copy expenses involved.
    4. If you believe that any information in your records is incorrect or missing important information, you can ask to have some kinds of changes (termed "amending") to your health information. You would have to make such a request in writing and send it to the office, and you would also need to write the reasons that you want to make the changes.
    5. You have the right to a copy of this notice and to the longer NPP. If I make any changes to either form, I will post the new version in the waiting room, and you could always get a copy of the new NPP from me.
    6. You have the right to file a complaint if you believe that your privacy rights have been violated.
  • You can file such a complaint with me personally and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint regarding privacy will not in itself change the health care that you receive at this office. If you have any questions regarding this notice or the health information privacy policies at this office, please contact Skin Deep, or go to to find out more information.
  • Date Format: MM slash DD slash YYYY
  • I have read and understand the above Notice.
  • Patient Consent for Latisse

    Latisse is a prescription treatment approved by the FDA to grow longer, thicker, and darker eyelashes.

    Latisse is believed to affect the growth phase of the eyelash hair cycle in 2 ways; first, it increases the length of the “growth” phase; and second, it increases the number of hairs in the “growth” phase. The exact way in which Latisse works is still unknown.

    The onset of results is gradual but usually a significant improvement is noted after 2 months of nightly use. You should not use Latisse solution if you are allergic to one of its ingredients. Also it is important to let your physician know if you answered “yes” to any of the following questions.
  • Possible side effects (reported by approximately 4% of users in the Latisse clinical trial) would include:
    - Eye itching
    - Eye redness

    Other less common side effects occur on the skin close to where Latisse is applied or in the eyes.
    - Eye irritation
    - Dryness or redness of the eyelids
    - Darkening of eyelid skin which may be reversible
    - Darkening of the eye color, for instance, hazel, green or blue eyes change to brown (likely to be permanent) this was not seen in the clinical trials for Latisse, however has been documented when the product is used as an eye drop for glaucoma.
    - Unwanted hair growth in an adjacent area (This did not appear to be a permanent effect)
  • If you develop a new eye condition (like an eye trauma or infection), experience a sudden decrease in vision, have eye or eyelid surgery, or develop any eye or eyelid reactions, particularly an infection, or if you become pregnant, you should immediately talk to your doctor about whether or not to continue using Latisse solution.
  • Date Format: MM slash DD slash YYYY


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