Glasgow Eye Doctor
Before completing this questionnaire you must read the
Important Safety Information
Medical Questionnaire: Treatment of hypotrichosis (insufficient eyelashes)
with Bimatoprost 0.03%
Name:
*
Date of Birth (dd/mm/yyyy):
*
Address line 1:
*
Address line 2:
*
City:
*
State:
*
Zip Code:
*
Country:
*
Telephone:
*
Email:
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1. Is your eyelash growth inadequate and/or do you feel that you would like to have eyelashes that are thicker, darker or longer ?:
*
Yes
No
2. Are you currently pregnant or breast feeding ?:
*
Yes
No
3. Do you plan to become pregnant or to breastfeed during the treatment period ?:
*
Yes
No
4. Do you agree that if you should discover that you are pregnant during the treatment period that you will stop the treatment immediately ?:
*
Yes
No
5. Are you over 18 ?:
*
Yes
No
6. Do you have any active problems with your eyes or eyelids ?:
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Yes
No
7. Have you ever been told in the past that you have might have glaucoma, an abnormal eye pressure, iritis (eye inflammation), macular oedema (fluid in the back of the eye ), or have you ever had eye surgery ?:
*
Yes
No
8. Are you physically able to make a face to face Consultation with the prescribing Doctor ?:
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Yes - please arrange this for me
No - but I confirm that I have had a normal eye examination with a qualified ophthalmic optician in the last 12 months
No - and I have not had my eyes examined in the last 12 months
9. Do you suffer from hair loss ?:
*
Yes
No
10. Are you currently taking any medicine, including both non- prescription and prescription medications ?:
*
Yes
No
Please list any medications here
11. Are you allergic to any medicines ?:
*
Yes
No
Please list any allergies here
12. 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 :
*
Yes
No
13. I confirm that I have read and understood all the important safety information about Bimatoprost 0.03% on this website :
*
Yes
No
14. I understand the alternative treatment options, the possible side-effects, and efficacy of the treatment described and I give my informed consent to be prescribed Bimtoprost 0.03% off-label for the treatment of insufficient eyelashes :
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Yes
No
15. I agree that any medicine prescribed will be taken only by the person whose details are given above, and no one else :
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Yes
No
16. I agree to read and follow the instructions that accompany any medicine that is prescribed and dispensed :
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Yes
No
17. I agree to notify the Doctor if I experience side effects, if I develop any new eye problems, or if I am planning to have eye surgery during the treatment period:
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Yes
No
18. 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:
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Yes
No
19. 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 can be expected to return to their original dimensions :
*
Yes
No
20. I agree to arrange regular (6 monthly) checks of my eyes whilst I am taking the medication:
*
Yes, but I am not physically able to see the prescribing Doctor for checks - I will instead see a qualified ophthalmic optician for regular checks and contact the prescribing Doctor if needed
Yes, I wish to have followup appointments with the prescribing Doctor - please arrange this for me
No
21. The Doctor needs to check that you are suitable to be prescribed the medication. If the Doctor is able to prescribe this medication for you, how many bottles would like to have (each bottle lasts 1 month) ?:
*
1 bottle
2 bottles
3 bottles
4 bottles
22. Do you wish your GP to be informed of any treatments that you may be prescribed ?:
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Yes
No
If yes please provide your GP contact details here
23. Do you have any questions for the prescribing Doctor ?:
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Yes
No
Please ask any questions here
24. If you are suitable for treatment, our pharmacy team will contact you to collect payment and arrange delivery to your home. Please let us know the most suitable time you can be contacted by telephone in the space below. If you wish to provide alternate contact details please let us know as well.