UpneeqTM Consent Form

UpneeqTM Consent Form
UpneeqTM (oxymetazoline hydrochloride ophthalmic solution) is an FDA-approved prescription for acquired ptosis (low-lying lids)
Patient Name*

First NameMiddle NameLast Name
Sex*

FemaleMale
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
Patient Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Risks and Possible Side Effects of Using UpneeqTM

Please review and select each bullet below to indicate that you understand the risks and possible side effects of using UpneeqTM, have been given the opportunity to speak with a healthcare provider about this in more detail and have any questions answered.
*

Eye inflammation/irritation
*

Dry eye
*

Blurred vision
*

Eye pain
*

Headache
*

Class of Upneeq (alpha-adrenergic antagonist) may affect patients' blood pressure.
*

In the studies, there was no report of side effects related to blood pressure and some patients reported mild blurring when instilling the drops which subsided rapidly.
Contraindications of using UpneeqTM

You should not use UpneeqTM if any of the following apply to you:
- Uncontrolled/untreated glaucoma
- May cause increased eye pressure
Patient's Acceptance of Risks

Please read and select each of the following options to indicate that you have read, understand, and have been given the opportunity to discuss this product and its intended treatment with a healthcare professional in order to answer any questions you may have.
*

I have read the above information and have been given the opportunity to schedule an appointment with a physician or other healthcare provider to discuss this at length
*

I understand that it is impossible for the physician to inform me of every possible complication that may occur
*

I understand that use of this medication is cosmetic, elective, and optional
*

I have been informed that results are not guaranteed.
By signing below, I agree that all of questions have been answered by a healthcare professional and I give informed consent to proceed with UpneeqTM treatment. *

Clear
Date Signed*

MonthDayYear
Date
My Products*
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UpneeqUPNEEQ (oxymetazoline hydrochloride ophthalmic solution) - the only FDA-approved treatment for acquired ptosis (low-lying lids)
$240.00

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Total

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UpneeqTM Consent Form

Risks and Possible Side Effects of Using UpneeqTM

Contraindications of using UpneeqTM

Patient's Acceptance of Risks