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Complete to Purchase

I would like to use UPNeeq eye drops to help my low-lying eyelids. I understand this is a prescription drug and requires me to provide my accurate medical history to ensure I am a good candidate for the drops. I agree to complete the following questions accurately and to the best of my knowledge so I can safely use UPNeeq and will be contacted by my provider for further information. I also understand that due to state regulations I must reside in New York, New Jersey, or Connecticut to receive UPNeeq from this provider and that UPNeeq is not returnable.


After this form is completed and reviewed a prescription will be submitted to RVL pharmacy and you will be emailed and texted a link from RVL directly allowing you to order your supply of UPNeeq which will be delivered to the address you choose.





First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Second Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Third Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fourth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Fifth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Sixth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Seventh Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Eighth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Ninth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Tenth Patient Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Patient Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical History
Have you been diagnosed with glaucoma?*
No
Yes
Have you been diagnosed with hypertension (high blood pressure)?*
No
Yes
If you answered "Yes" to the above question, is your hypertension well controlled?*
Not Applicable
No
Yes

If you are currently taking any medications, please list below.
Do you currently wear contact lens?*
No
Yes

I understand if I wear contact lens I will remove my lens prior to putting UPNeeq in my eyes and wait 15 minutes before reinserting my lens.

Based on the information you provided, a provider will review your history and will contact you. If there is any other information you would like to provide please do so below.  Once your information has been reviewed prior to receiving your prescription, a pharmacist will also reach out to you to ask if you have any other questions.



Medications
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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