Please complete this medical questionnaire before your appointment. A copy of this has been emailed to you as well. If your answers are all OK, then the prescriber may decide to email you a confirmation of prescription.

Once it has been prescribed, you will receive an email explaining how the medicine will be delivered to you. If you have any questions, please call us on 0141 404 6545. 

 

 

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Name
I will contact my GP myself, you do not have my permission to contact my primary care providers about my care.
I am not currently pregnant, and will take (if appropriate) precautions against this during therapy with Purelash.
I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation for Purelash. I have completed research on the registered USA product "Latisse" or similar materials and understand what I am asking for is an unlicensed medicine and as such, formally disclaim all prescribers and dispensers from any or all harm caused. If appropriate I authorise Dickson Chemist to take over managing my repeat prescriptions and working with my prescriber directly. I understand that this a PRIVATE non-NHS service which will attract cost for prescribing and dispensing. I confirm that I am not pregnant or breastfeeding and will take adequate precautions during my therapy period. I will upload the following items below: * Baseline photograph of eyelashes* Scan or photo of photographic ID *
Click or drag files to this area to upload. You can upload up to 5 files.