D2D 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
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex*

FemaleMale
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
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 Upneeq, have been given the opportunity to speak with a healthcare provider about this in more detail and have any questions answered.
Punctate keratitis (A sign of eye inflammation)
Eye redness
Dry eye symptoms
Blurred vision
Eye pain at the instillation site (the spot where the medicine drops into your eye)
Eye inflammation/irritation
Headache
Use UPNEEQ carefully if you currently take an alpha adrenergic agonist medications to treat heart disease or an enlarged prostate
Patients who use a certain class of antidepressant medication (monoamine ox inhibitors) should use carefully
Contraindications of using UpneeqTM

You should not use UpneeqTM if any of the following apply to you:
- You have cardiovascular disease
- You have blood vessel problems, such as Sjögren’s syndrome
- You have glaucoma
- You are allergic to the ingredients
- You are pregnant
- You are breastfeeding
- You are under 13 years old
I understand I cannot use Upneeq with contact lens in my eye
I understand I must wait 15 minutes before using Upneeq with other eye drops
I understand that I cannot use Upneeq with blood pressure medications that contain alpha agonists such as drugs with beta blockers (drugs ending in-olol) and ACE inhibitors like lisinopril
I understand that I cannot use Upneeq with monoamine oxidase inhibitors(MAOIs). Examples include Zyvox, selegiline, and phenelzine
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
Patient Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Signed*

MonthDayYear
Date
Should be Empty:

UpneeqTM Consent Form

Risks and Possible Side Effects of Using UpneeqTM

Contraindications of using UpneeqTM

Patient's Acceptance of Risks