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  Latisse (3 ml. Bottle - 70 Disposable Applicators) (Moolala Offer) (3A02-QWQW-C03)

Redeeming Your Moolala Offer

  1. Fill form below and add product to cart.
  2. Enter your Moolala coupon at checkout.
  3. Discount automatically calculated. Limit 1 coupon per customer.
MSRP: $144.00

Basic Info


  Date of Birth



Medical History

What medical conditions do you have, if any.

What medications are you currently taking, if any.

Please list the drug allergies that you have, if any.

If you are pregnant, nursing, or taking fertility drugs, please specify above.

If you have any other medical condition or information that we need to know, please specify above.

Medical Conditions

NO. I have not been diagnosed with any of the below conditions.
Hypersensitivity to Latisse/Lumigan/bimatoprost
Ocular inflammation
Macular edema
Increased intraocular pressure

Informed Consent

In order to purchase Latisse online, you must fill out the Intake and Informed Consent form below.

  • Latisse is an FDA approved product that requires a prescription.
  • Once you have filled this form out, you will be given instructions on how to make payment with your credit card.
  • To ensure the most optimal results, our customer service will be in touch with you by email after your purchase. accepts U.S. Orders only. is an authorized Allergan Latisse Representative, which ensures your safety.

I request and consent to receive Latisse eyelash enhancer for the purpose of lengthening, thickening, and darkening my eyelashes. I understand that as part of the program I will be given the Latisse formula with supporting materials and will be instructed on how to administer the drops myself. I understand that this initial intake form will be necessary to rule out any conditions that would disqualify me from the program. I will obtain this form from

I understand Latisse is FDA approved for lengthening, thickening, and darkening of the eyelashes. I agree that I am, and will be under the care of another medical provider for all other conditions. can work in conjunction with, but cannot replace, regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand the physicians with only prescribe Latisse for the treatment of lengthening, thickening, and darkening eyelashes. does not accept or bill insurance for this program.

Prior to my treatment, I have fully disclosed any medical conditions or diseases such as: pregnancy, breastfeeding, history of glaucoma, aphakia (absence of lens in the eye), macular edema, ocular inflammation, hypersensitivity to Latisse (or bimatoprost), or other serious medical condition. Any contraindications for the use of Latisse have been fully disclosed to me.

I understand that use of Latisse is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform if I am pregnant, could be pregnant, or should become pregnant during the course of the treatments.

While Latisse is mostly free of negative side effects with any medication there is the possibility of an allergic reaction or unusual reactions that may cause conjunctival hyperemia (redness of eyes), itchy eyes, dry eyes, visual disturbances, ocular blurring, foreign body sensation, periorbital skin darkening, blepharitis, keratitis, eyelid erythema, ocular irritation, iris discoloration, or photophobia.. I understand that the medications may involve risk.

I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that there are risks involved as there are with all medications and that not complying with the dosage recommendations could increase risks and alter my results from the program. I understand that I may quit the program at any time. No adverse side effects or complications are expected, but in the event that an illness does occur, I understand that I need to contact If I experience an emergency situation, I understand that I need to go to an emergency facility.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this treatment. I will also inform of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.

Your typed name at the bottom of the form is equivalent to your signature.

Digital Signature

Electronic Signature (First and Last Name)

Email Address

Phone Number

Optional - Brilliant Distinctions

    Brilliant Distinctions (BD) Account # (10 Digits)
    Birth Month and Day for looking up BD Account (MM/DD)

Already have Brilliant Distinctions? Please enter your 10 Digit Member # here. This will help us ensure that you get Brilliant Distinctions points for your Latisse, Vivite, and SkinMedica purchase.

Not a Brilliant Distinctions member yet? You can quickly create one HERE.


How to Redeem Your MOOLALA Offer

  1. Fill the purchase form, and add the Latisse (Moolala Offer) product to cart.
  2. Enter the whole Moolala coupon at checkout (e.g., MLLA9ABCDEF).
  3. Discount automatically calculated. Limit 1 coupon per customer.

Brilliant Distinctions Program

  • Earn Points each time you purchase Latisse, Vivite, or SkinMedica.
  • Redeem Points for coupon codes that can be used on phone orders at Please call us at 213-984-4677, Mon-Fri, 8:30 AM-5 PM (PST).
  • For additional information, please refer to the official Brilliant Distinctions Program website. (Another browser window will open.)

Customer Service

To ensure the most optimal results, our customer service will be in touch with you by email after your purchase. Or, if you have any questions regarding Latisse, please e-mail us at or call (213) 984-4677 Monday to Friday between 8:30AM to 5PM (Pacific Standard Time).

Product Description

Latisse is the only FDA-approved prescription treatment for hypotrichosis which is inadequate or not enough lashes. Designed to improve the length, thickness and darkness of your natural lashes, this revolutionary formula contains the powerful ingredient Bimatoprost which affects the life cycle of lashes. Users of Allergan Latisse have reported noticeable results in just 4 weeks of continued use with full results appearing in 16 weeks.

Clinical Results

Latisse - Clinical Results


Ensure the face is thoroughly clean and contact lenses are removed. Once nightly, place one drop of LATISSE® on the disposable sterile applicator supplied with the package and apply evenly along the skin of the upper eyelid margin at the base of the eyelashes. The upper lid margin in the area of lash growth should feel lightly moist without runoff. Blot any excess solution runoff outside the upper eyelid margin with a tissue or other absorbent cloth. Dispose of the applicator after one use. Repeat for the opposite eye using a new sterile applicator.


Active: Bimatoprost. Other Ingredients: Benzalkonium Chloride, Sodium Chloride, Sodium Phosphate, Dibasic, Citric Acid, Purified Water.

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