Browsing articles from "April, 2012"

Tumescent Liposuction Surgery Consent Form

Consent Forms // No Comments

SAVE THIS FORM TO YOUR COMPUTER BY USING THE DOWNLOAD BUTTON. A PREVIEW IS DISPLAYED BELOW.

PLACE LETTERHEAD HERE AND REMOVE NOTE.
CHANGE FONT SIZE FOR LARGE PRINT

NOTE: THIS FORM IS INTENDED AS A SAMPLE FORM. IT CONTAINS THE INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED INFORMED CONSENT.
Version 12/2/2002

(Courtesy of Emilio M. Justo, MD, a practicing ophthalmologist in Sun City West, AZ.)

CONSENT FOR TUMESCENT LIPOSUCTION SURGERY

Liposuction is a body contouring and sculpting technique. It is a means of reducing localized fat deposits that are difficult or impossible to remove with diet or exercise. Liposuction is not a technique for treating obesity. In the tumescent technique of liposuction, a very dilute anesthetic solution is injected under the skin into the fatty tissue before it is removed. Afterward, compression garments are worn for drainage and support. Patients usually return to work after 2 to 7 days.

I clearly understand and accept the following:

The goal of liposuction surgery, as in any cosmetic procedure, is improvement – not perfection.
The final result may not be apparent for 3 to 6 months post-operatively.
In order to achieve the best possible result, a “touch-up” procedure may be required.
Areas of “cottage cheese” texture (i.e. cellulite) will be changed little by the liposuction procedure.
Liposuction surgery is a contouring/sculpting procedure and is not performed for purposes of weight reduction, nor as a substitute for healthy diet and exercise.
Strict adherence to the post-operative regimen and instructions is necessary in order to achieve the best possible results.
I have not taken any aspirin or aspirin-containing products for a minimum of two (2) weeks prior to my surgery.
There is no guarantee, expressed or implied, that the expected or anticipated results will be achieved.
I understand that liposuction surgery is contraindicated in certain patients (see below) and that I am not one of these patients:
Women who are pregnant or believe they might be pregnant
Women who are nursing
Patients with active thrombophlebitis or active infection
Patients with poor circulation or confined to bed
Patients with a history of pulmonary embolism or blood clots in the lungs
Patients with a history of severe or multiple allergic reactions
Patients with uncontrolled diabetes mellitus or uncontrolled collagen vascular disease (e.g. Lupus, etc.)
Patients with a history of uncontrolled bleeding
Patients with positive blood tests for hepatitis, HIV, or AIDS
I authorize and consent to the usage of photographs or video taken before, during, or after surgery for teaching, marketing, scientific journals, and other viewing purposes.

Although complications following liposuction are infrequent, I understand that the following may occur:

Skin irregularities, lumpiness, hardness, and dimpling may appear post-operatively. Most of these irregularities disappear with time and/or massage, but localized irregularities may persist permanently. If loose skin is present in the treated area, it may or may not shrink to conform to the new contour.
Infection is rare, but should it occur, treatment with antibiotics and/or surgical drainage may be required.
Numbness or increased sensitivity of the skin over treated areas may persist for months. Rarely, it is possible that localized areas of numbness or increased sensitivity could be permanent.
Normal temporary side effects associated with liposuction surgery include soreness, inflammation, bruising, swelling, numbness, and minor irregularity of the skin. Some of these effects can take several months to resolve.
________
Initial
Objectionable scarring or pigment changes is unusual because of the small size of the incisions used in liposuction surgery, but scar formation or permanent pigment changes are possible.
Dizziness may occur during the first 24 to 48 hours following liposuction surgery, particularly upon rising from a lying or sitting position, or when removing compression garments. If this occurs, extreme caution must be taken while walking. Do not attempt to drive a car if dizziness is present.
Surgical bleeding is very rare using the tumescent technique of liposuction surgery; however, it could theoretically require hospitalization.
Temporary accumulation of fluid under the skin (seroma) may occur, requiring possible surgical drainage.
In addition to these possible complications, I am aware of the general risks inherent in all surgical procedures and anesthetic administration. Although rare with tumescent liposuction surgery, unexpected severe complications can occur, including but not limited to: allergic reaction, paralysis, convulsions, blood clots, strokes, heart attack, brain damage, or even death.
In the event of an emergency, I hereby give my consent to my transfer to a nearby hospital. I understand that I am responsible for any transportation expenses incurred for my care during the time I am in transit between institutions, as well as any hospital, physician, laboratory, or radiological expenses.
I confirm the surgeon and his/her staff have explained to me the nature, purpose, limitations, and possible consequences of liposuction surgery, as well as risks involved and possible complications. I understand the explanation I have received is not exhaustive and that other, more remote risks and consequences may arise. I have been advised that a more detailed and complete explanation of any foregoing matters will be given to me is I so desire, and I do not desire such further explanation. All questions have been answered to my satisfaction.
The following is/are the area(s) of my body to be treated by liposuction: (circle and initial)

____   Abdomen, Lower   ____   Thighs, Outer   ____   Hips
____   Addomen, Upper   ____    Infero-Lateral Buttocks   ____   Waist
____   Male Flanks   ____    Thighs, Inner   ____   Female Flanks
____   Male Breasts   ____    Knees, Inner   ____   Posterior Axillary
____   Chin, Jowls, Neck   ____    Thighs, Anterior   ____   Arms
____   Platysmal Plication   ____    Knees, Anterior   ____   Buttocks

Patient Name (Printed) Patient Signature Date/Time

Witness Name (Printed) Witness Signature Date/Time

Physician/Staff Declaration: I have explained the contents of this document to the patient and have answered all the patient’s questions, and to the best of my knowledge, the patient has been adequately informed. The patient has consented, and has been given a copy of this consent form.

Staff Signature Date/Time

Physician Signature Date/Time

IMPORTANT INFORMATION ABOUT TUMESCENT LIPOSUCTION

Risks of Liposuction Surgery: Any surgery involves the risk of infection, bleeding, scarring, or serious injury. However, tumescent liposuction has an amazingly good safety record. One of the reasons that tumescent liposuction is safer than other liposuction techniques is that general anesthesia is not required. The greatest risks of liposuction are those associated with general anesthesia. By eliminating general anesthesia, the risks of liposuction are dramatically reduced.

Patients can minimize the risk of surgical complications by not taking medications or over-the-counter preparations that might adversely affect the surgery. Patients should inform the surgeon of any medications being taken regularly, or occasionally, including herbal remedies.

Risk of Irregularities of the Skin: Tumescent liposuction using microcannulas is the least likely to cause any significant or noticeable post-surgical irregularities of the skin. By magnifying the fatty compartment, the tumescent technique permits more accurate removal of fat, with greater assurance that the liposuction cannula will not inadvertently approach too near the undersurface of the skin, which would cause irregularities. Thus, the tumescent technique helps to minimize the risk of post-surgical irregularities or rippling of the skin. Liposuction might improve pre-existing irregularities of the skin such as dimpling, but prospective patients should not assume that there will be significant improvement. It is unrealistic to expect perfectly smooth skin. Patients should expect that their skin will have approximately the same degree of dimpling and irregularities as existed before tumescent surgery. Ultimately, after liposuction the skin texture should be within normal limits. A casual observer should not notice any evidence of surgical irregularities of the skin. However, it is possible that a noticeable irregularity of skin may result and require touch-up surgery.

Risk of Scarring of the Skin: Incisions for liposuction may result in scarring. The incisions made for inserting the cannulas are usually less than 2 to 3 mm in length and are usually virtually invisible once healed. Although you may be able to find them upon close examination, most other people would not be able to see them. Some patients may experience temporary hyper-pigmentation (darkening) that usually fades after several months. Some patients may have a genetic predisposition for persistent discoloration at the incision sites. Patients that have experienced hyper-pigmentation, or hypo-pigmentation (pale or light-colored scars) in the past might expect to also experience it with these incisions. Certain areas of the body, such as the back or upper flanks, may be more likely to have pigmentation changes.

Cellulite: Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle “puckering” of the skin often called “cellulite.” Cellulite results from the pull of fibrous tissue that connects skin to underlying muscle. While tumescent liposuction may reduce the degree of cellulite, it is unlikely to eliminate it. Liposuction should not worsen cellulite.

Liposuction and Obesity: Liposuction is not an appropriate treatment for obesity. Liposuction is not a substitute for a prudent diet, good nutrition, and regular exercise. Obese patients may be good candidates for limited liposuction if their goal is simply to improve the shape of certain limited areas of the body.

Postoperative Healing: Normal healing after tumescent liposuction involves a limited but definite degree of soreness, swelling, bruising, and lumpy firmness. A temporary mild numbness of the skin may persist for up to 4 months. Most patients can actually see some improvement of their silhouette within one week after surgery. However, because of the slow resolution of post-surgical swelling, the ultimate results following liposuction usually require 12 to 24 weeks to be achieved.

________
Initial

Realistic Expectations: Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. It is impossible to guarantee the precise amount of improvement that will result from liposuction. Patients should not have unrealistic expectations. Although patients can usually expect to achieve at least a 50% improvement, it is unreasonable to expect 95% improvement or near perfection. For the perfectionist, or for liposuction of a very large area, maximum improvement may require a second procedure for which an additional fee may apply.

Patients who would be satisfied with a 50% improvement would be reasonably good candidates for liposuction. The “50% Improvement” is intentionally a vague measure. It indicates a definite perceptible improvement, but something short of perfection. If a 50% improvement would make a patient happy, then it is likely that these expectations will be met.

Longevity of Results: The fat cells that are removed by liposuction do not grow back. If the patient later gains or loses weight, the change tends to be distributed proportionately over the entire body. Although one can expect some changes with aging, provided that the patient does not gain large amounts of weight, the new, more pleasing silhouette is relatively permanent.

Patient Name (Printed) Patient Signature Date/Time

Witness Name (Printed) Witness Signature Date/Time

This sample consent form is provided courtesy of Emilio M. Justo, MD, a practicing ophthalmologist in Sun City West, Arizona.

Restylane Injection Consent Form

Consent Forms // No Comments

SAVE THIS FORM TO YOUR COMPUTER BY USING THE DOWNLOAD BUTTON. A PREVIEW IS DISPLAYED BELOW.

REMOVE NOTE AND PUT ON LETTERHEAD
CHANGE FONT SIZE FOR LARGE PRINT
Please review the form, modify it to fit your actual practice, and place on your letterhead. Please offer the patient a copy of the form. The last page serves to verify that the surgeon has obtained informed consent from the patient; it can be copied and sent to the ambulatory surgery center if needed as verification of consent. This consent form is intended as a sample only and is provided as a risk management service. It is not intended to constitute a standard of care and should not be relied upon as a source for legal advice. If legal advice is desired or needed, an attorney should be consulted.
Version 12/20/06

Consent for Restylane Injection

Indications. Restylane® is a sterile gel consisting of stabilized hyaluronic acid; Medicis, the manufacturer, states that it is biodegradable, and safely and completely metabolized by the body. Restylane® injections are given to correct facial wrinkles and/or for lip augmentation. Restylane® has been approved by the FDA (Food and Drug Administration) for correction of facial wrinkles in the nasolabial area (nose-lips) and the fold between the cheek and the nose/upper lip (“on-label” use). I understand that the safety and effectiveness of treating facial areas other than the nasolabial folds has not been studied; however, Restylane® has been used to enhance the appearance of lips in over 60 other countries. This “off-label” aspect of the treatment has been explained to me.

Alternatives. There are alternatives to Restylane® injections, including no treatment, collagen for lip or other facial soft tissue augmentation, and cosmetics, Botox, laser skin resurfacing, chemical peels, or plastic surgery for wrinkle reduction.

Results. I understand that the actual degree of improvement cannot be predicted or guaranteed. Furthermore, I understand that the effect will gradually wear off and additional treatments may be necessary to maintain the desired effect.

Side effects and complications include but are not limited to:
•   Potential allergic reaction. As with any product, allergies can develop during or after injection.
•   Injection site reactions: a lumpy or “thick” feeling at or just under the skin, bruising, redness, itching, pain, tenderness, or slight swelling.
•   Injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections) for patients with a history of prior cold sores.

Precautions and contraindications
•   Due to the potential for an allergic reaction, Restylane® is not recommended for patients with severe allergies or a history of anaphylaxis.
•   The risk of bruising or bleeding may be increased by medications with anticoagulant effects, such as aspirin and non-steroidal anti-inflammatory drugs (e.g., Ibuprofen, Aleve, Motrin, Celebrex), high doses of Vitamin E, and certain herbs (Ginkgo Biloba, St. John’s Wart).
•   The safety of Restylane® in pregnant or breast-feeding women has not been established, and is therefore not recommended for these women.

Consent
I understand the need for local anesthesia to reduce the discomfort of the procedure and consent to the topical application of anesthetic gel and/or injections for a nerve block or local infiltrative anesthesia. I understand the above, and have had the risks, benefits, and alternatives explained to me, and have had the opportunity to ask questions. No guarantees about results have been made. To the best of my knowledge, I am not pregnant, and I am not breastfeeding. I give my informed consent for Restylane® injections today as well as future treatments as needed.

_______________________________ _________________________
Patient Signature Date

Punctal Plugs Consent Form (Courtesy of Bernard H. Chang, MD, a practicing ophthalmologist in Nashville, TN.)

Consent Forms // No Comments

Condition and Proposed Treatment
My ophthalmologist has diagnosed me with dry eye syndrome. Typical symptoms of this condition include burning and (paradoxically) watering and a sensation like something is in the eye. In many cases dry eyes are caused by the body’s failure to produce enough tears. Blocking the tear drainage system with punctal or intracanalicular (tear duct) plugs may improve symptoms by keeping more tears in the eye. Severe cases of dry eye may lead to infection and in rare cases, blindness or loss of the eye.

Alternatives
1.   Artificial tears or ointment – Lubrication increases moisture on the surface of the eye. Depending on severity, these over-the-counter drops and ointments may be applied several times daily for maximal comfort
2.   Restasis – Used twice daily, this prescription eye drop increases production of the body’s own tears.
3.   Surgical tear drainage closure – The punctum and canaliculus may be surgically occluded by thermal cautery (heat) or ligation (suture closure). These methods should be considered permanent.
4.   No Treatment – I may choose to do nothing and tolerate the symptoms of my dry eye condition.

Risks
1.   Infection – The punctal plug is a foreign material and may be associated with infection around the plug. Infections can be treated with antibiotics and removal of the plug.
2.   Excessive Tearing – In some cases, plugs may cause an overflow of tears. Your doctor may decide to remove the plugs in this situation.
3.   Irritation – The exposed end of the punctal plug may cause irritation and need to be replaced with a different size plug or removed.
4.   Loss of the Plug – The punctal plug may fall out or need to be replaced.
5.   Retention of plug in or permanent scarring of the tear duct – Although rare, plugs may become lodged in the tear drainage pathway (canaliculus) or cause scarring. Surgery may be necessary to re-establish tear drainage

Consent For Treatment
By signing below, I acknowledge that I have read and understand the above and have had the opportunity to discuss this information with my doctor to my satisfaction. I consent to the insertion of punctal plugs in the (PLEASE CIRCLE)

RIGHT lower upper LEFT lower upper eyelid(s)

____________________________________ ____________________
Patient Signature Date

Ptosis Surgery Consent Form

Consent Forms // No Comments

SAVE THIS FORM TO YOUR COMPUTER BY USING THE DOWNLOAD BUTTON. A PREVIEW IS DISPLAYED BELOW.

PLACE LETTERHEAD HERE AND REMOVE NOTE. Version 07/20/2009
CHANGE FONT FOR LARGE PRINT
NOTE: THIS FORM IS INTENDED AS A SAMPLE ONLY OF THE INFORMATION YOU AS THE SURGEON SHOULD PERSONALLY DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE.
IT IS IMPORTANT TO DOCUMENT AND EXPLAIN THE ETIOLOGY OF THE CONDITION CAUSING THE DROOPY EYELID AND HOW THAT CONDITION MIGHT AFFECT THE RESULTS OF SURGERY.
GIVE THE PATIENT A COPY.

Informed Consent for Ptosis Surgery
(Droopy eyelid surgery)

WHAT IS PTOSIS AND HOW IS IT CORRECTED?

Ptosis is a condition that occurs when one or both upper eyelids droop and the edge of the upper eyelid falls towards or over the pupil . Ptosis is usually caused by stretching or thinning of the tendon between the muscle that raises the eyelid and the eyelid itself. With stretching or thinning, the muscle that normally raises the eyelid has to work harder to lift it. This leads to symptoms of eyelid and forehead muscle fatigue, and eyelid heaviness. Other, less common causes of ptosis are nerve or muscle damage from any cause, various types of eyelid surgery, infection, muscle weakness, and systemic diseases such as stroke and tumors behind the eye, myasthenia, hypertension, thyroid disorders and diabetes. Children can be born with congenital ptosis; the muscle is abnormally stiff and does not function well. This condition usually lasts until it is surgically corrected. Ptosis surgery is not the procedure of choice for removing excess fat and skin in the upper eyelid. Under certain circumstances it can be combined with the operation known as blepharoplasty when fat and skin removal is an added goal of surgery.

To correct ptosis, the surgeon needs to make an incision or cut the skin of the upper eyelid in order to reach the muscles and tendons. The surgeon chooses where to make the incision based upon what treatment the eyelid needs. With the front or anterior approach, the surgeon makes an incision in the skin in the upper eyelid crease or fold in order to reach the muscle and tendon; if there is no eyelid fold, one can be created when the incision is made. The anterior approach allows the surgeon to trim excess skin and fatty tissue from the upper eyelid if needed during the surgery. If no skin or fat needs to be removed, the surgeon can raise the eyelid through an inside approach by placing the incision on the inside or moist part of the upper eyelid; with this approach, there is no cosmetic scarring. If the muscle is not strong enough to lift the eyelid, the surgeon must create a “sling” by connecting the moving eyelid to the frontalis muscle in the forehead.

HOW WILL PTOSIS SURGERY AFFECT MY VISION AND APPEARANCE
The droopy eyelid is like a curtain that blocks the view. Patients with ptosis frequently notice that they have less peripheral or side vision, particularly when looking up. The more ptosis, the greater the peripheral vision loss. When the eyelid is raised, either manually by hand, or surgically through one of the approaches described above, the blockage is removed and the eye can see. Ptosis surgery only corrects vision loss due to droopy eyelids. It does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye. To prevent amblyopia or poor visual development in children born with congenital ptosis, the surgery needs to be done early in life.

Patients with ptosis report that droopy eyelids make them look and feel “tired.” When the eyelid is raised in ptosis surgery, patients usually prefer the new eyelid position, and feel it improves their appearance as well as their peripheral vision. When only one eyelid is raised, it may affect how the eyelid on the other side looks. If this happens, ptosis surgery on the other side may be needed. If the position and shape of the eyelids do not match, additional surgery may be needed.

WHAT ARE THE MAJOR RISKS OF PTOSIS SURGERY?

Risks of ptosis surgery, like most eyelid surgical procedures include but are not limited to: bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), a “wide-eyed” or “open” appearance, difficulty with or inability to wear contact lenses, double vision, tearing, or dry eye problems, numbness and/or tingling in the operated eyelid, near the eye, or on the face, and in rare cases, loss of vision. While ptosis correction is usually permanent, the condition can recur. If it does, you may need to have repeat surgery.

The result of ptosis surgery cannot be guaranteed. Ptosis correction involves surgery on the tendon and/or muscle inside the eyelid, which can make the results unpredictable. At times, the surgeon may need to adjust the position and shape of the eyelid after ptosis surgery. The adjustments can be done early (within the first ten days) after surgery, or later on if asymmetry of the eyelid position or shape occur. The final result depends upon your anatomy, your body’s wound healing response, and the underlying cause of the ptosis. Some patients have difficulty adjusting to changes to their appearance. Some patients have unrealistic expectations about how changes in appearance will impact their lives. Carefully evaluate your goals, expectations and your ability to deal with changes to your appearance and the possible need for repeat surgery before agreeing to this surgery.

WHAT ARE THE ALTERNATIVES TO PTOSIS SURGERY?

Patients can live with ptosis and blocked or reduced peripheral vision; however, there is no reliable method to correct ptosis on a permanent basis without surgery. Patients who are too sick to have surgery may find relief by lifting their eyelid with their fingers or tape in order to see. Obviously, the eyelid droops again as soon as this temporary lifting is stopped.

WHAT TYPE OF ANESTHESIA IS USED AND WHAT ARE ITS RISKS
In children, general anesthesia is necessary. In teenagers and adults, ptosis surgery is usually performed on an outpatient basis under local anesthesia. The patient must be able to cooperate to some degree. Ptosis surgery with minimal (oral) sedation is desired in most cases. Some cases require sedation from a needle placed into a vein in your arm before surgery. Fortunately, even with no sedation, most patients do not find the operation to be very painful, and it only takes a short period of time. Risks of anesthesia, when administered, include but are not limited to damage to the eye and surrounding tissues and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.

Patient’s acceptance of risks

I have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed and that adjustments and more surgery may be necessary. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of ptosis correction.

I consent to ptosis surgery on:

________ Right eye _________ Left eye _________ Both eyes

_________________________________________ _____________
Patient (or person authorized to sign for patient) Date

Latisse™ Treatment Consent Form

Consent Forms // No Comments

Click here for the AAO prescribing recommendations for Latisse.

SAVE THIS FORM TO YOUR COMPUTER BY USING THE DOWNLOAD BUTTON. A PREVIEW IS DISPLAYED BELOW.

PLACE LETTERHEAD HERE AND REMOVE NOTE. Version 07/01/2009
CHANGE FONT FOR LARGE PRINT
NOTE: THIS FORM IS INTENDED AS A SAMPLE ONLY OF THE INFORMATION YOU AS THE PHYSICIAN SHOULD PERSONALLY DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE. GIVE THE PATIENT A COPY.

(Courtesy of John W. Shore, M.D., a practicing ophthalmologist in Austin, Texas.)

INFORMED CONSENT FOR LATISSE™ TREATMENT

(Treatment for hypotrichosis)

WHAT ARE THE INDICATIONS FOR LATISSE™ TREATMENT?
Latisse™ is the brand name for bimatoprost, a sister medication already FDA approved for the treatment of glaucoma known as Lumigan®. LatisseTM is FDA approved for the treatment of hypotrichosis of the eyelashes by making them grow longer, thicker and darker. Hypotrichosis is a medical term for short or missing lashes. It is frequently seen in men and women as they approach middle age. Latisse™ is believed to affect the growth (anagen) phase of the eyelash hair cycle by increasing the length of the growth phase and increasing the number of hairs along the eyelid margin. The onset of action is gradual with most users seeing a significant improvement in the length and number of lashes by 2 months. If Latisse™ is discontinued the eyelashes and eyelids will return to their previous appearance over several weeks to months.

Alternatives: There are no FDA approved alternatives. You may decide that you do not want to use Latisse™ now and are willing to live with short or missing eyelashes.

WHAT ARE THE RISKS and POSSIBLE SIDE EFFECTS OF USING LATISSE™?
1.   The following side effects are the most frequently reported, but occur in less than 4% of users (i.e. 4 out of 100 users):
a.   Eye irritation and itching
b.   Conjunctival hyperemia or red eye (redness of the white, moist covering of the eyeball)
c.   Dry eye symptoms
d.   Eyelid redness
2.   Although rare, Latisse™ has the potential to permanently increase the brown pigmentation of the iris (colored part of the eyeball, inside the eye).
3.   Latisse™ may cause hyperpigmentation or darkening of the eyelid skin which may or may not be reversible upon discontinuation of the treatment.
4.   Latisse™ may lower intraocular pressure (IOP) or pressure inside the eye; however, the magnitude of this reduction is usually not a cause for concern.
a.   If you have a history of abnormal eye pressures or glaucoma you should only use Latisse™ under the close supervision of your ophthalmologist.
b.   Inform anyone conducting an eye pressure examination that you are using Latisse™.
5.   You should inform your ophthalmologist that you are using Latisse™ if eye surgery is planned.
6.   Do not use Latisse™ if you are allergic or hypersensitive to bimatoprost (LumiganR) or any other ingredient in this product.
7.   Latisse™ is intended for use on the skin at the base of the eyelashes of the UPPER eyelids only.
8.   DO NOT APPLY to the lower eyelids as this will increase the chance of side effects such as hyperpigmentation or darkening of the eyelid skin.
9.   You should discontinue use of Latisse™ and call your physician immediately if you develop an eye infection, sudden decrease in vision, suffer eye trauma, or develop eye or eyelid reactions.

WHAT ARE THE CONTRAINDICATIONS OF USING LATISSE™?
You should NOT use Latisse™ if: you are allergic or hypersensitive to bimatoprost (LumiganR) or any other ingredient in this product; are about to undergo cataract or other eye procedures, have an intraocular inflammation (uveitis), have risk factors for macular edema, have an eye infection, or are being treated for glaucoma with eye drops, unless cleared by your treating ophthalmologist. LATISSE™ is not approved for people under the age of 18. It is not recommended for pregnant or lactating women.

PATIENT’S ACCEPTANCE OF RISKS
I have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed. By signing below, I agree that my physician has answered all of my questions and I give informed consent to proceed with Latisse™ treatment.

Patient Signature Date

Witness