Indications – Prescription treatment for acquired blepharoptosis (drooping eyelid) in adults, used to temporarily lift the upper eyelid and improve visual field.

UPNEEQ SCREENING 

1. Do you have a history of eye pressure issues, including glaucoma or use of IOP-lowering medications? …..Y …..N
2. Are you pregnant or breastfeeding? …..Y …..N
3. Do you experience any of the following symptoms / conditions:
   
   1. a. Dry eyes …..Y …..N
   2. b. Red or irritated eyes …..Y …..N
   3. c. Frequent eye allergies …..Y …..N
   4. d. Uncontrolled hypertension …..Y …..N
   5. e. Heart disease or recent cardiovascular issues …..Y …..N
   6. f. Eye infections or recent eye surgery …..Y …..N
4. Do you have a history of narrow-angle glaucoma or other significant eye conditions? …..Y …..N

IMPORTANT:

If you answered Yes to #1, #2, or #4, you may not be a candidate for Upneeq.
If you answered Yes to any part of #3, we recommend you consult your Ophthalmologist or primary care provider prior to starting Upneeq.

UPNEEQ WARNINGS, PRECAUTIONS, & POTENTIAL SIDE EFFECTS
Do not use Upneeq if you are currently using medications that affect blood pressure or intraocular pressure without medical clearance.

Upneeq may increase blood pressure or worsen certain cardiovascular conditions in rare cases. Upneeq should not be used in patients with untreated narrow-angle glaucoma.

Common side effects may include:

• Eye redness or irritation
• Dryness or blurred vision
• Headache
• Ptosis rebound (eyelid may appear lower when effect wears off)

Avoid contact of the dropper tip with any surface to prevent contamination.

Remove contact lenses before use. Wait at least 15 minutes before reinserting.
Use only as directed—one drop in each affected eye per day.

If side effects persist or worsen, discontinue use and consult an eye care professional.

CONSENT
Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform PDO Lift and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.