Online Medical Questionaire

Available on doctor prescription only

Please complete your online medical questionnaire
Only available for 18 year-old and above living in the UK

Please complete the following medical questionnaire before proceeding to buy Lumigan Eyelash Serum. Your details will remain confidential and will only be accessible by our clinic. Your details will be checked by the doctor before dispatching the Eyelash serum to your address. You may be contacted by the doctor if further information is needed. You will receive a full refund if the doctor finds you are not suitable for the treatment.

First Name

Last Name

Phone Number

Date Of Birth

Is it the first time you order the Eyelash Serum from this website?

Yes, it is my first time No, I have mad a previous order

Shipping Address Line 1

Shipping Address Line 2

City

Post Code

Country

1) Are you at least 18 years of age and living in the UK? *

Yes

2) Are you currenly taking any eye drops? *

If ''Yes'' please give details.

3) Have you ever suffered from or received treatment for any eye conditions, including active intraocular inflammation, glaucoma or macular oedema? *

If ''Yes'' please give details.

4) Are you currently pregnant or breastfeeding, or do you plan to become pregnant or breastfeed over the treatment course? *

No I'm not, and I will stop using the Eyelash Serum if I become pregnant or start breastfeeding

5) I agree that only the above named person will use Lumigan Eyelash Serum prescribed by our clinic and that all the information I have given are true to the best of my knowledge and that I have not withheld information that could potentially be judged as relevant to a Doctor *

Yes, I agree

6) If there are additional information that you think might be relevant, please tell us.

7) How did you hear about us?

Tell us more if you selected ''Others''.