Upload one “before“ photo (week 0 or pre-treatment) and one “after“
photo (taken at week 16 or later). We want to see your real results, so no mascara
or eye makeup! And be sure to fill out the fields below. If you've submitted before,
please use the same email address you used the last time.
Consent Form for Patient Testimonials
Hide Terms & Conditions
What is the purpose of this consent form?
From time to time, Allergan, Inc. (Allergan) solicits actual (real life) patient
experiences with its products, for purposes of including some of that information
in its advertising, promotion, training or market research evaluation programs.
By submitting your photographs and information, you may be selected as a possible
candidate for providing an actual patient testimonial about your use of Allergan’s
product, LATISSE®. However, there is a chance your submission may not be used.
What am I consenting to by checking this box?
By checking this consent box, you are giving Allergan, its affiliates, and other
business partners working with Allergan on its products, programs and services,
the right to use, copyright, license, publish, broadcast, display, reproduce, and
distribute in any manner, in color or otherwise, your name, personal information,
or personal experiences that you provide to Allergan, in connection with your use
of LATISSE®.
What am I representing to Allergan by checking this box?
You are representing that any statements and information that you have provided
to Allergan are accurate, and reflect your true and honest opinion of your experiences.
What can Allergan do with my photos or personal information
if I consent?
If you provide consent to Allergan, you may have your testimony, along with some
of your medical information relating to your personal experiences with LATISSE®
published, circulated or presented in any way in any media (e.g., internet, printed
advertisements, television or radio ads, annual reports and training programs) for
distribution to the public at-large. Allergan can use your information by itself
or combine it with other written, printed, graphic, or audio matter, for members
of the medical, nursing, pharmaceutical and related healthcare professions, as well
as to other patients and consumers.
Will Allergan share my information with any other parties?
Allergan may share your information with its affiliated companies and other business
partners for purposes relating to advertising, promotion, training or market research
programs that relate to Allergan products, programs or services. These parties will
only be allowed to use your information consistent with this consent form, and will
not be permitted to use your information for their own separate use. The business
partners who may receive your information includes advertising agencies and public
relations firms working with Allergan on its advertising and promotional activities.
Will Allergan or its business partners contact me?
In some situations, business partners may contact you to discuss your experience
with LATISSE®, for the purpose of evaluating appropriate candidates for testimonials.
Am I entitled to any payments or ongoing compensation from
the use of my photos or information?
No. There is no compensation or reimbursement for participation in this program.
Can I withdraw my consent?
Yes, you can withdraw your consent at any time by sending a written request to withdraw
to Allergan, Inc., Attention: Corporate Communications, P.O. Box 19534, Irvine,
CA 92623. Please allow 30 days from receipt of your request for processing. If you
withdraw your consent, it will apply to new uses of your information, but will not
apply to any use of your information that is already initiated, such as advertising
or promotional materials that have already been prepared for use. Allergan, Inc.
does not have an obligation to cease using promotional materials that have already
been prepared with your information.
What am I releasing by checking this box?
By checking this box, you understand that you are releasing Allergan from any legal
claims arising out of the use of your photographs or information by Allergan, its
affiliates and its business partners, consistent with the allowable uses provided
in this consent form.
