Demo Intake — Eyelash Growth | Evolve Health (Preview)

Eligibility Gates

Are you having any urgent symptom listed above right now? *

NoYes

I confirm each of the following (all must apply): *

I am 18 years of age or older.I am physically located in Texas during this evaluation.I understand this is not emergency care.I understand a Clinician will review my answers and treatment is not guaranteed.

Your date of birth *

About You

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care? *

Phone callText messageSecure portal message

May we leave a generic voicemail (no medical details)? *

YesNo

Identity Verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart. If your ID cannot be fully verified, any prescription is pickup only. Prescriptions are picked up at your own pharmacy. If your ID cannot be verified, a video visit may be needed first.

Photo of the FRONT of your government ID *

Take a photo

Demo only — files are never uploaded.

Upload a photo

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Photo of the BACK of your ID — the barcode side *

Take a photo

Upload a photo

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Selfie *

Take a photo

Upload a photo

Look at the camera like a passport photo — no sunglasses or hat.

*The name and date of birth on my ID match the information on this form.

Your Concern and Goals

What would you like help with? Check all that apply. *

Grow longer, fuller, darker eyelashesRefill eyelash growth treatment I already useEyelashes became thinner after illness, medication, or another treatmentOther

Your main goal for this visit

Have you used an eyelash growth serum or prescription lash treatment before? *

NoYes

If yes: product name, how long you used it, and any side effects

Contact Lenses and Eye Habits

Do you wear contact lenses? *

NoYes

If you wear contact lenses: remove your lenses before applying the treatment at night, and wait at least 15 minutes before putting them back in. The treatment can be absorbed by soft contact lenses and can discolor them.

Do you wear eye makeup, lash extensions, or use lash tinting or lash lifts? *

Eye makeupLash extensionsLash tint / liftNone of these

Apply the treatment to clean skin with makeup removed, using a fresh applicator for each eye each night. Do not share applicators, and do not reuse them — this keeps the medicine sterile and lowers infection risk.

Do you rub your eyes often, or have eczema or dermatitis on your eyelids? *

NoYes

If yes, describe — include dates

Medicines and Allergies

List every prescription medicine, over-the-counter medicine, vitamin, and supplement you currently use (eye medicines were listed above — you do not need to repeat them). Include dose and how often you take it. *

Medication allergies or serious reactions — include any reaction to eye drops or latex (write “None” if none) *

Have you ever had an allergic reaction, severe redness, or a color change from a lash serum or eye product? *

NoYes

If yes, describe — include dates the product and the reaction

Counseling Acknowledgments

Please read each statement carefully. Eyelash growth treatment works gradually and changes how some eyes and eyelids look. These changes are a normal, disclosed part of this medicine — the Clinician will not prescribe unless you understand and accept them.

Check each statement to confirm you understand: *

The skin of my eyelids may darken. This is usually reversible after I stop the treatment.The colored part of my eye (iris) may gradually turn browner. This change is likely to be permanent.Results are gradual: most people see fuller lashes at about 8 weeks, with full results at about 16 weeks of nightly use.If I stop the treatment, my lashes will gradually return to how they looked before.Hair may grow on skin the medicine repeatedly touches; I will blot any extra solution and apply only as directed.I will apply the treatment only to the upper eyelid lash line, exactly as directed — never inside the eye and never to the lower lash line.Low pressure inside the eye is a possible effect; if I use glaucoma or eye-pressure drops, I told the care team above and will follow the Clinician's instructions.

Reporting Instructions

After starting treatment, contact Evolve Health promptly through the portal or at (940) 257-2002 if you notice any change in your vision, eye pain, increasing redness, itching or irritation that does not settle, darkening of the iris or eyelid, or any new eye concern. Seek same-day in-person care for vision loss, severe eye pain, or an eye injury. Report changes early — the Clinician can adjust or stop treatment, and early reporting keeps your eyes safe.

*I understand the reporting instructions above and will report eye changes promptly.

Anything else about your eyes or this treatment you would like the Clinician to know?

How You Will Receive Medication

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.

Pharmacy pickup: *

Pharmacy pickup — prescription sent to the pharmacy I name belowMail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Pharmacy name and city (for pickup) *

What Happens Next and Consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; request a video or in-person eye evaluation; request records from your eye care clinician; or recommend in-person care instead of online treatment. No medicine is promised.

Payment: your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

Type your full legal name to confirm each statement: *

The information I provided is complete and accurate to the best of my knowledge.I listed all medicines, supplements, eye drops, allergies, and relevant health conditions.I understand a Clinician may require video, examination, records, photographs, or testing before deciding.I understand submitting this form does not guarantee treatment or a prescription.I understand telehealth has limits and I may be directed to urgent, emergency, specialist, or in-person care.I attest that I am the person named on this form, I am 18 years of age or older, and I am physically in Texas during this evaluation.I will seek emergency care for any emergency warning symptom listed at the top of this form.

Full legal name (acts as your signature) *

Eligibility Gates

About You

Identity Verification

Your Concern and Goals

Eye Health Screen

Contact Lenses and Eye Habits

Health History and Pregnancy Screen

Medicines and Allergies

Counseling Acknowledgments

Reporting Instructions

How You Will Receive Medication

What Happens Next and Consent

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Demo complete