Consultation form

All of the information that you enter is confidential and will never be disclosed. We do not share any information with other companies and all forms are reviewed only by UK based medical doctors.

Your full name

Your email

Date of birth

Have you ever suffered from or been treated for any eye conditions, including active intraocular inflammation and macular oedema?

Do you suffer from hair loss?

If yes, provide details:

Are you currently taking any medicine, including both prescription and non- prescription medicines?

If yes, provide details:

Are you allergic to any medicines?

If yes, provide details:

Are you currently pregnant or breast feeding, or do you plan to become pregnant over the treatment course?

I understand the possible side-effects, alternative treatment options and efficacy of the treatment described and I give my informed consent to be prescribed according to the terms and conditions of this service.

I agree to notify Mylash if I experience side effects

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.

I agree that any medicine prescribed will be taken by the person whose details are given above, and no one else.

I agree to read and adhere to the instructions that accompany any treatment that is prescribed and dispatched.

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 will return to their original dimensions.

Would you like us to contact your GP and inform them of any treatments that you may be prescribed?

If yes, provide details: