UpneeqTM Consent Form
UpneeqTM (oxymetazoline hydrochloride ophthalmic solution) is an FDA-approved prescription for acquired ptosis (low-lying lids)
Please review and sign this consent form and remit payment for Upneeq to be shipped to you, prescribed by Dr. Lily Talakoub
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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.
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:
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
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UPNEEQ (oxymetazoline hydrochloride ophthalmic solution) - the only FDA-approved treatment for acquired ptosis (low-lying lids)
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