Balfour Dermatology

2221 Balfour Road, Suite A

Brentwood Ca, 94513          

  Dr. Robert E. Beer M.D.

  (925) 240-9116

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Release of Liability:
I accept full responsibility for any and all adverse side effects that may occur if I choose to use Latisse. I hereby release Balfour Dermatology, Dr. Robert Beer, Allergan and the staff of Balfour Dermatology of any and all liability in connection with the use of Latisse.
Consent To Treat:
With respect to Latisse, I waive my option to be seen in person and agree to use Latisse as intended and directed. My electronic signature below is my consent for you to treat me as our patient. I understand and am fully informed on the product and agree to order the Latisse product online. 
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