Balfour Dermatology

2221 Balfour Road, Suite A

Brentwood Ca, 94513          

  Dr. Robert E. Beer M.D.

  (925) 240-9116

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PATIENT INFORMATION FORM:
First Name: * Last Name: *
Address 1: *
Address 2:
City: * State: * Zip Code *
Email: *
Phone: *
 
Have you ordered from us in the past?
Are you current pregnant, trying to get pregnant, or breast feeding? 
 
Please list all Medication Allergies (If none, enter none):
 
Please list all Eye Medication you are currently taking (If none, enter none)
 
Please list any chronic eye conditions and/or eye surgeries (If none, enter none)
 
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. 
 
Your Electronic Signature (please type both your first and last name here)
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