Eyelash.com - Eligibility Form

Eyelash.com has partnered up with EyelashGrowthStore.com whom has made the ultimate ordering and servicing of Latisse, safe, fast, easy and secure!

Their elite group of doctors quickly, efficiently and ethically process your application. Upon approval, your payment and shipment will be made through EyelashGrowthStore.com.

You will receive email confirmation and tracking information through EyelashGrowthStore.com, any issues regarding shipments or payment should be made directly to: info@eyelashgrowthstore.com.

$104.99/ea with Free UPS Ground within the US only! *
Name * First Last
Birth Date * / MM / DD YYYY
Phone * - (###) - ### ####
Email *
Are you a . . . * New Customer Refill
Please Review the following information * I have reviewed all of the information provided on the Medical Consent Form & the FAQ's pages.
Consent to Treat: * With respect to Latisse®, my typed name above is equivalent to my signature and is my consent for you to treat me as your patient.
Have you ever used Latisse® in the past? * Yes No
Please list all your Medication Allergies here: *

If you have no medication allergies Please type none.
What Medical or Eye Conditions do you have that you are currently being treated for? Please list them here, including Eye or Other medications you are currently using: *

If you have no medical conditions Please type none.
Have you had any surgeries, including any eye surgery? Please list them here: *

If you have no medical conditions Please type none.
Currently Pregnant? * No, I am NOT currently pregnant, nursing, or planning on getting pregnant while using Latisse. (Effects are unknown in the clinical study.)
You should not use Latisse If you are currently pregnant, nursing, or planning on getting pregnant!
I hereby release: * Cesar Caldera, M.D., Vatche Bardakjian, M.D., Allergan, Inc & Brains & Beauty, Inc dba: EyelashGrowthStore.com of any and all liability in connection with using this product.
Please Read the Following: * Yes, I waive the option to be seen in person for medical evaluation.
I certify that: * All of the information provided by me here is true and correct, and if approved, agree to use Latisse as intended and directed.
Privacy Policy * I have read and agree to the Privacy Policy
My electronic signature: * is also proof to you that I understand and feel informed about the product, and agree to the online ordering option.
You acknowledge: * I acknowledge that my electronic signature above is my signed acceptance that all information submitted is true and correct.
Electronic Signature *

Please type your First AND Last name HERE
To protect us & you, do you accept: * Yes, I will not dispute the credit card charges after I receive Latisse, I also accept UPS and/or USPS Delivery Confirmation as proof of Latisse delivery to me.
Would you like to stay informed about new promotions and/or other available discounts? * Yes No
Would you like to add a $32.95 Lip Plumper from Vivite? * Yes No
How did you hear about us?

Please select an option to indicate how you heard about us. If your selection is not displayed please enter it on the next field
If other please enter here

If your choice is not listed, please indicate here
If a friend referred you, please enter their full name.
Credit Card Information

Your credit card will not be charged untill you receive a Consultation phone call.
Full Name on Credit Card *
Billing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

**For International Customers, shipping and handling will be added to your order.
Credit Card Type *
Credit Card Number *
CV2 *

Turn your card over and enter the last 3 digits.
Exp. Date *
If you're Billing Address is different from your Shipping, please enter your Shipping Address here.

For international customers, shipping and handling will be added to your order.
Enter Shipping Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Enter Shipping Address IF it is different from Billing Address

Eyelash.com - Eligibility Form

Eyelash.com - Eligibility Form

Credit Card Information

If you're Billing Address is different from your Shipping, please enter your Shipping Address here.