All of the information that you enter is confidential and will never be disclosed. We do not share any information with other companies and all forms are reviewed only by UK based medical doctors.
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Have you ever suffered from or been treated for any eye conditions, including active intraocular inflammation or macular oedema?no yes
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Do you suffer from hair loss?no yes
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Are you currently taking any medicine, including both prescription and non- prescription medicines?no yes
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Are you allergic to any medicines?no yes
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Are you currently pregnant or breast feeding, or do you plan to become pregnant over the treatment course?no yes
I understand the possible side-effects , alternative treatment options and efficacy of the treatment described. I give my informed consent to be prescribed according to and agreeing to the terms and conditions of this service.—Please choose an option— yes
I agree to notify Opti Laboratories if I experience side effects—Please choose an option— yes
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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.—Please choose an option— yes
I agree that any medicine prescribed will be taken by the person whose details are given above, and no one else.—Please choose an option— yes
I agree to read and adhere to the instructions that are emailed to me for any treatment that is prescribed and dispatched.—Please choose an option— yes
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I agree that this treatment is not guaranteed to be effective and that even if it is effective, if I stop taking the medicine then my eyelashes will return to their original dimensions.—Please choose an option— yes
Would you like us to contact your GP and inform them of any treatments that you may be prescribed?no yes
Would you like disposable applicators instead of the slide brush applicator?no yes
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