Patient Profile - UPNEEQ

Step 1 of 3 - Basic Information

First Name *

Last Name *

Email *

Phone *

Gender

Date of Birth *

Physicians Name

Physicians Phone Number

Step 2 of 3 -Photo & ID Upload

Upload Government ID *

Upload Full Face Photo

Step 3 of 3 -Medical history

Have you ever used UPNEEQ before? *

List ALL MEDICATIONS you are taking (include eye drops). If no medications, enter none. *

List ALL MEDICAL CONDITIONS. If no medical conditions, enter none. *

List ALL ALLERGIES to medications. If no allergies, enter none. *

Do you take medication for high blood pressure? *

If yes, please list your blood pressure medications: *

Do you have Sjogren’s syndrome, Narrow Angle Glaucoma, and/or Myastheria Gravis? *

Do you take medication for depression? *

If yes, please list any antidepressant medication you take. *

Do any of the following conditions apply to you? *

I have had low lying eyelids since I was young
A stroke has affected my eyelids
I have a lump, growth, or stye on my eyelid
I have an active eye infection
I have had an injury in the past that has affected my eyelids
None of the Above

* I hereby acknowledge that Med Spa By Alana and Skincarebyalana.com cannot submit my prescription to the Pharmacy until I have fully completed all of the requirements including the medical history form and uploading photos or a face-to-face video consultation (depending on my states telemedicine laws), which includes presenting my government issued ID to verify my identity. I understand that my prescription will only be shipped after all information is reviewed by a Med Spa By Alana and Skincarebyalana.com medical practitioner and I am deemed to be a good candidate for the prescription product I selected. * *

* I have read and understand the Upneeq Informed Consent form *Click here to Read Consent Form *

* I have read and understand the TERMS AND CONDITIONS OF SALE and PRIVACY POLICY. I understand that completed prescription orders cannot be canceled, refunded, or returned. I understand that I can contact a Med Spa By Alana and Skincarebyalana.com medical practitioner at any time via telephone or email with any further questions and concerns. By completing my purchase, I agree that all of my questions have been answered and I give informed consent to proceed with the prescription product treatment. *Click here to view PRIVACY POLICY Click here to view TERMS AND CONDITIONS OF SALE *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Summer Wedding Gift Guide

Guaranteed Safe Checkout

Need Help?

Top Pages

Store Info

Get Discounts and be Beautiful

Log In

Forgot Password

Create an Account

Authorization

Log In

Forgot Password

Create an Account