Eyelash Logic Approval

Name *
Name
Are you currently taking any medicine, including both prescription and non- prescription medicines? *
Are you allergic to any medicines? *
Have you ever suffered from or received treatment for any eye conditions, including active intraocular inflammation, glaucoma or macular oedema? *
Are you currently pregnant or breastfeeding, or do you plan to become pregnant over the treatment course? *
Are you at least 18 years of age? *
I understand the possible side-effects, alternative treatment options and efficacy of the treatment described and I give my informed consent to be prescribed according to the terms and conditions of this service. *
Should I experience side effects, I agree to notify Eyelash Logic. *
I agree that all information I have given is true to the best of my knowledge and that I have not withheld information that could potentially be judged as relevant to a doctor's decision to prescribe. *
I agree that only the above named person will use any medicine prescribed by Eyelash Logic. *
I agree to read and adhere to the instructions that accompany any medicine that is supplied by Eyelash Logic. *
I agree that this treatment is not guaranteed to be effective and that even where it is effective, if I stop taking the medicine then my eyelashes will return to their original condition. *
Would you like us to inform your GP of any prescription you may be offered? *
I confirm that I have read the Terms and Conditions. *