Thank you for your order

John Doe

Thank You For Your Order #0

Your Order is Confirmed

If you are a returning customer and there have been no changes then there is nothing else to do.

If you are a new client or if you would like to update your medical form then please complete the following medical questionnaire.

We can only arrange for your order after this form has been completed.

A confirmation mail has been sent to john.doe@example.com with your order details.

Have you ordered from Opti Laboratories or Mylash before?

Have you completed a medical form before a previous order?

Has your health changed?

There is no need to complete a medical form again. Thank you.

Please complete this medical form so we can process your order. Press the next button below.

Please complete this form to let us know about the changes to your health. Press the next button below.

Your full name

Your email

Date of birth

Have you ever suffered from or been treated for any eye conditions, including active intraocular inflammation or macular oedema?

Do you suffer from hair loss?

If yes, provide details:

Are you currently taking any medicine, including both prescription and non- prescription medicines?

If yes, provide details:

Are you allergic to any medicines?

If yes, provide details:

Are you currently pregnant or breast feeding, or do you plan to become pregnant over the treatment course?

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.

I agree to notify Mylash if I experience side effects

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 any medicine prescribed will be taken by the person whose details are given above, and no one else.

I agree to read and adhere to the instructions emailed to me for any treatment that is prescribed and dispatched.

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.

Would you like us to contact your GP and inform them of any treatments that you may be prescribed?

If yes, provide details:

Would you like disposable applicators instead of the slide brush applicator?

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John Doe​