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!

Gerda Spillmann

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