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. 

Name *

First

Last

Address: *

Date of birth – please note you must be over 18. Minors must have a face to face consultation with a registered doctor or pediatrician – call us on 0141 404 6545 option 1 for a referral. *

Email *

Best phone number to get you on *

Who is your primary care physician (GP) as we may need to talk to them about your request unless you opt out *

I will contact my GP myself, you do not have my permission to contact my primary care providers about my care.

• Tick here

I am not currently pregnant, and will take (if appropriate) precautions against this during therapy with Purelash. *

• Tick here

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 * *

• Agree

Do you have any current eye problems other than those adequately corrected by glasses or contact lenses?NoYes

Have you ever been told in the past that you have might have glaucoma, iritis (eye inflammation), or macular oedema (fluid in the back of the eye ?)NoYes

Have you had a normal eye examination by an ophthalmic optician in the last 12 months ?YesNo

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

If YES please give details

I understand that results are not instant, and that regular applications must be given over several months before a change in the eyelashes may be seen.YesNo

Medical evidence upload. 1) Picture of current eye lash 2) Photographic ID or selfie holding a household bill *

Click or drag files to this area to upload. You can upload up to 5 files.

Additional Comments / Tell us a little bit about yourself and your pertinent medical history *

Submit