Email a Friende-mail
Print this Pageprint

2012 Patient Testimonial Information Form

Personal Information

Patient
First name: *
Last name: *
Age: *
Home Address
Address 1: *
Address 2:
City: *
State: *
Zip Code: *
Telephone
Home: *
Daytime: *
E-Mail Address: *
I may be contacted in regards to the information included in my testimonial
I would like to continue receiving information about Euflexxa®

How did you hear about this program (check all that apply)?
My physician PA/nurse
Mailing from physician's office Other (please specify)
      
Information card/flyer in
physician's waiting room

Treatment Information

Date Euflexxa® treatment began:
Month:
Year:

Total number of completed treatments with Euflexxa®(course of 3 injections):
Treatments:

Prior to treatment with Euflexxa®, had you tried other medications?
Yes No
Aspirin
Acetaminophen
Ibuprofen
Naproxen
Topical pain medications
Prescription medications
Cortisone (steroid injections)
Hyaluronan injections other than Euflexxa® (please specify brand)
Other (please specify)

Prescribing Physician Name
First name:
Last name:

Practice Name

Practice Address
Address 1:
Address 2:
City:
State:
Zip Code:

Physician Office Telephone
Physician Office Fax

Upload Testimonial Photos (optional):
Your Testimonial: *


Patient Authorization and Release

I, *, allow *(physician), to give my health information regarding the treatment of my 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 my osteoarthritis of the knee.

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 * (physician), 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 publicationmedical 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.


EUFLEXXA (1% sodium hyaluronate) is used to relieve knee pain due to osteoarthritis. It is used in people who do not get enough relief from simple pain medications such as acetaminophen or from exercise and physical therapy.

Important Safety Information
You should not receive this product if you have had any previous allergic reaction to EUFLEXXA or hyaluronan products. You should not have an injection into the knee if you have a knee joint infection or if you have skin disease or infection around the injection site.

EUFLEXXA is only for injection into the knee performed by a qualified doctor. After you receive this injection you may need to avoid activities such as jogging, tennis, heavy lifting, or standing on your feet for a long time (more than one hour). The safety and effectiveness of repeat treatment cycles of EUFLEXXA have not been established. The safety and effectiveness of EUFLEXXA have not been shown in people under 18 years of age.

Side effects sometimes seen when EUFLEXXA is injected into the knee joint were pain, swelling, skin irritation, and tenderness and these were generally mild and did not last long.

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.