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2011 Physician Testimonial Information Form

Physician Information

Physician

First name:

Last name:

Age:

Practice Name:

Office Address

Address 1:

Address 2:

City:

State:

Zip Code:

Office Phone:

Office Fax:

E-Mail Address:

How did you hear about this program (check all that apply)?

www.Euflexxa^®.com	PA/nurse
My sales representative	A patient
A colleague	Other (please specify)

Your Testimonial: *

guidelines and Release

I, *, confirm that the attached testimonial reflects the results of treatment with Euflexxa^® within the FDA-approved treatment indication. I am submitting the attached health information regarding the treatment of knee osteoarthritis to Ferring Pharmaceuticals, Inc. its affiliated companies, subcontractors, vendors and/or partners (collectively "FPI"), for the purposes of the Stand Up to Knee OA 2009 initiative. This information may include spoken or written facts about a patient's treatment with Euflexxa^®.

I understand that such health information, photographs, medical images shall become the property of FPI and may be shown, published, printed, broadcast or otherwise disseminated in any print, visual or electronic media, specifically including, but not limited to, videotapes, CD-ROM, Internet Web cast, online slide collection, newspapers, television, medical journals and textbooks. I release and discharge FPI and all parties acting under their license and authority from all rights that I may have in the health information, photograph(s), or medical image(s), including any claim for payment in connection with their distribution or publication.

I understand that, to the extent permitted by law, I have the right to inspect and copy the health information, photograph(s), or medical image(s) that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization.

I understand that the health information, photograph(s), or medical image(s) disclosed, or some portion thereof, may be protected by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I further understand that, because FPI is not receiving the health information, photograph(s), or medical image(s) in the capacity of a health care provider or health plan covered by HIPAA, the health information, photograph(s) or medical image(s) may be redisclosed and may no longer be protected by HIPAA.

By signing this form, I certify that I have read the above authorization and release and fully understand its terms, and that Ferring Pharmaceuticals may use my submitted testimonial and images in press materials, publications and promotional materials, as well as on its Web site(s) and at promotional events.

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EUFLEXXA (1% sodium hyaluronate) is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics (e.g., acetaminophen).

Important Safety Information
EUFLEXXA is contraindicated in patients who have a known hypersensitivity to hyaluronate preparations or who have knee joint infections, infections, or skin disease in the area of the injection site.

EUFLEXXA should not be administered through a needle previously used with medical solutions containing benzalkonium chloride. Do not use skin disinfectants for skin preparation that contain quaternary ammonium salts.

Do not inject intravascularly due to potential for systemic adverse events.

The safety and effectiveness of injection in conjunction with other intra-articular injectables, or into joints other than the knee have not been studied. Remove any joint effusion prior to injecting. Transient pain or swelling of the injected joint may occur after intra-articular injection with EUFLEXXA.

The most common adverse events related to EUFLEXXA injections reported in 12- and 26-week clinical studies were arthralgia, back pain, pain in extremity, musculoskeletal pain, and joint swelling. In an open-label extension of the 26-week clinical study with repeat series of injections, the most common adverse events related to EUFLEXXA at Week 52 were arthralgia and joint swelling.

Please see Full Prescribing Information.

Please see Important Information for Patients.

Patient Treatment Information

PLEASE CONSULT WITH YOUR DOCTOR, OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL BEFORE USING ANY PRODUCT DISCUSSED WITHIN THIS WEB SITE.

This website is intended only for US residents.

Euflexxa® is a registered trademark of Ferring Pharmaceuticals Inc.