Eye Lash Consultation Form

Online Consultation Form for Bimatoprost 0.03% Ophthalmic Solution (Unlicensed Indication: Eyelash Growth) Please complete this consultation form accurately. Your responses will help our prescriber determine whether Bimatoprost 0.03% is suitable for you. If approved, a prescription will be issued. All information is confidential and handled in compliance with GPhC and MHRA guidelines.

Step 1 of 5

Name(Required)

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Date of Birth(Required)

Gender(Required)

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Address(Required)